Structured Settlement Quote Form

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CONTACT INFO

First Name*

Middle Name or Initial

Last Name*

Current Address*

Current City*

Current State*

Current ZIP*

Day-Time Phone *   (e.g. 000-000-0000)

Evening Phone     (e.g. 000-000-0000)

Email Address*

Please Provide the Information about the Structured Settlement Payments Below

GENERAL INFO

Insurance Company Making the Structured Settlement Payments*

Are the Payments the Result of Workmen's Compensation?*

Do You Have the Benefit Declaration Sheet?*

State In Which Your Structured Settlement Was Filed*



EQUAL PERIODIC PAYMENTS

Payments to Be Quoted That Are of an EQUAL AMOUNT and Are Paid on a Regular Periodic Frequency of a Year or Less

Equal Periodic Payment Amount*

Equal Periodic Payment Frequency*

Number of Even Periodic Payments to Be Sold*

First Even Periodic Payment to Be Sold (Date)*

Last Even Periodic Payment to Be Sold (Date)*

                                                     Do Periodic Payments Increase?*

(If Yes, Explain in Comment Box Below)



LUMP SUM PAYMENTS

Payments to Be Quoted That Are NOT of an Equal Amount AND Have an Irregular Payment Frequency

DUE DATE* LUMP SUM AMOUNT DUE*

COMMENT BOX: Enter Below Any Information About Your Transaction That We Should Know Before Contacting You:Comment:

Please Be As Accurate As Possible Because Your Answers Will Affect The Quotation.
If you are unsure, CALL Toll Free at: 1-800-322-5985 or send your request via FAX Toll Free at: 1-800-340-8138.

On Which Search Engine or Directory Did You Find Us:

CLICK on Submit Structured Settlement Information Button to Send Data

OR

Send Us an E-mail Defining Your Particular Situation:
ClientServices@capitalfundingofamerica.com

If You Have Experienced Trouble with this Web Site
Please Contact the Webmaster at the Following E-mail Address:
webmaster@capitalfundingofamerica.com

website: www.capitalfundingofamerica.com

Capital Funding of America,Inc.
714 Eletson Drive
Crystal Lake, IL 60014
Toll Free: 1-800-322-5985 Local: 815-788-0888
Fax: 1-800-340-8138

Form: Structured Settlement Quote Ver. 2.3

CONTACT INFO
First Name*
Middle Name or Initial
Last Name*
Current Address*
Current City*
Current State*
Current ZIP*
Day-Time Phone *	(e.g. 000-000-0000)
Evening Phone	(e.g. 000-000-0000)
Email Address*

GENERAL INFO
Insurance Company Making the Structured Settlement Payments*
Are the Payments the Result of Workmen's Compensation?*
Do You Have the Benefit Declaration Sheet?*
State In Which Your Structured Settlement Was Filed*

EQUAL PERIODIC PAYMENTS
Payments to Be Quoted That Are of an EQUAL AMOUNT and	Are Paid on a Regular Periodic Frequency of a Year or Less
Equal Periodic Payment Amount*
Equal Periodic Payment Frequency*
Number of Even Periodic Payments to Be Sold*
First Even Periodic Payment to Be Sold (Date)*
Last Even Periodic Payment to Be Sold (Date)*
Do Periodic Payments Increase?*	(If Yes, Explain in Comment Box Below)

LUMP SUM PAYMENTS
Payments to Be Quoted That Are NOT of an Equal Amount	AND Have an Irregular Payment Frequency
DUE DATE*	LUMP SUM AMOUNT DUE*