Welcome to Premium Finance Solutions

www.premiumfinancesolutions.com

Annuity/Structured Settlement Payments Application

CCFC/Referral Representative Information:

Name:

Company:

Address:

City:

State:

Phone:

Fax:

Client Information:

Name:

SS #:

Address:

City		State:
Phone #		Date of Birth

Driver's License Number and State:

Marital Status:

Attorney's Name:

(if applicable)

Is payment a disability pension?

If so, does disabled pensioner have a second source of income?

Is client providing life insurance?

If so, amount of coverage:

Payment Information:

Annuity Payor:

Gross Payment Amount:

Tax Deductions: Federal: State:

Other deductions from gross

Description :

Amount:

Frequency of payments (number of months or years):

Date of next anticipated payment:

Client's Need:

What is the client’s motivation?

How much cash does the client need or want?

Premium Finance Solutions, Inc.
1911 Foothill Blvd., #149
La Verne, CA 91750-3511
909-964-1701 Fax: 413-751-9884
E-mail: pfsolutions@adelphia.net
"Insurance Premium Finance & Commercial Lending Solutions"
We are proud to be a member of the American Cash Flow Association.

QUICK LINKS:

• Mission Statement
• Insurance Premium Financing
• Reasons to Sell Cash Flows
• Asset Protection
• Selling Private Mortgage Notes
• Receivable Funding/Factoring
• Structured Settlements
• Leasing
• Apply Online