The following information are needed for us to grant your request in selling your structured settlement or annuity payments.  You may submit this form to us by printing it out and faxing it to us and we will contact you within 48 to 72 hours with a "lump sum" quote based on the information you provide us below. STRUCTURED SETTLEMENT/ANNUITY QUOTE SHEET Name_______________________________________ Phone____________________________ Fax__________________________ Date_____________________ E-Mail _________________________________ How did you find us ___________________ Name of Insurance Company ___________________ State You live in ________________ State settled in _________________ What type of settlement? __car accident __personal injury __wrongful death __other, explain ____ Was this work related? Y or N Have you sold payments before? Y or N Payments? __monthly __quarterly __annually __ combination Monthly Payment Amount _________________ Paid on what day of month ________________ When was the first payment _______________ When is the last payment _________________ Do payments increase? Y or N If yes, date and amount of increase _________ Lump sum payments? ___ Yes  No ___ Date ______ Amount _______ Date ______ Amount ________ Date ______ Amount _______ Date ______ Amount ________ Date ______ Amount _______ Date ______ Amount ________ Date ______ Amount _______ Date ______ Amount ________ How many payments would you like to sell? ______________ How much money would you like to raise?   ______________ _________________________ Print out and mail this sheet to:. Cash Flow Funding c/o O'Hara Enterprises 544 Norwood Street East Orange, NJ 07018 or call us with this information by phone: 973-474-6619