Quote Request

Please provide the following information and we will contact you ASAP. Required fields are denoted with a

First Name:
Middle Name (MI):
Last Name:
Address:
City:
State:
Zip:
Phone:
Email:

How did you hear about Annuity Transfers?

Best time to call:

Name of the insurance company making payments:

Are your payments associated with worker's compensation? Yes No

Do you receive monthly payments? Yes No

Monthly payment amount is:

The payments are being made by the insurance company
from to (mm/dd/yyyy)

Does the monthly payment stream increase annually? Yes No

If so, what is the percentage increase?

Do you receive annual or other lump sum payments? Yes No

Please list the date and amount of each payment
Date			Amount
Date			Amount
Date			Amount
Date			Amount
Date			Amount
Date			Amount

Do you have other payments you would like to sell? Yes No
List the date and amount of each payment
Date			Amount
Date			Amount
Date			Amount
How much money do you hope to receive by selling annuity payments?
Comments: