State in which client resides

What type of settlement?

Car accident     Personal injury     Wrongful death    

Other, please explain

Was this work related?  Yes  No
If Yes, then Beneficial Brokers can NOT complete this settlement.   
If No, then please continue to the next question.

Have you sold payments before?  Yes  No

If Yes, to what company? 

What payments? 

How are the payments paid out? 

Monthly     Quarterly     Annually     Combination

Monthly payment amount? 

Paid on what day of the month? 


           


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