The following questions are designed to help us evaluate your personal situation and qualify you for some potential alternative funding options in your retirement. This may include a cash settlement for all, or a portion, of an existing life insurance policy, a reverse mortgage and a personal annuity settlement. If you do not know all of the information, just do the best you can. We promise to do our best and get back to you as soon as possible.

What is the insured's name?


Insured's date of birth?


What is the insured's current health status?

What is the face amount or death benefit?



How would you prefer to be contacted?