Refer a Case or Request a Proposal

If you know the consultant to whom you wish to refer a case, please complete the form below. If you are unsure of which broker to send your case referral, please click here.

Your Contact Information

First Name:	Last Name:
Company Name, if Applicable:
Daytime Phone:	Fax:
Email:

Injury claim or workers' compensation settlement.
Employment, Commercial or Attorney fee settlement.
Illustration for a structured installment sale.

Injury Claim Settlement

Injured Party Information

First Name:	Last Name:
Date of Birth: Month: Day: Year: ex:2007
Gender: FemaleMale

Insurance Information

Type of Insurance Claim: Personal Lines (Against an Individual) Commercial Lines (Against a Company) Medical Malpractice Workers Compensation
Date of Loss: Month: Day: Year: ex:2007
Cash Settlement Amount:	Amount to Structure:
Defendant Insurer:	Defendant:
Insurance Claim Number:
State of Jurisdiction:	Name of SFA Broker you Prefer? If broker is not listed, enter the broker's name below:
Additional Information or Special Needs:
Submit

Employment, Commercial or Attorney Fee Structure

Claimant Information

First Name:	Last Name:
Date of Birth: Month: Day: Year: ex:2007
Gender: FemaleMale
Insurance Information
Insurance Claim Number:	Amount to Structure:
Defendant Insurer:	Defendant:
State of Jurisdiction:	Name of SFA Broker you Prefer? If broker is not listed, enter the broker's name below:
Additional Information or Special Needs:
Submit

Illustration for a Structured Installment Sale

Amount to Structure:
State of Jurisdiction	Name of SFA Broker you Prefer? If broker is not listed, enter the broker's name below:
Additional Information or Special Needs:
Submit

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Refer a Case or Request a Proposal

Injury Claim Settlement

Employment, Commercial or Attorney Fee Structure

Illustration for a Structured Installment Sale