Request a Proposal - Monarch Structured Settlements

Please complete/submit the below information to the best of your ability.

Attorney Name*
Attorney Firm*
Contact Person*
(Main point of contact for email communication, coordinating settlement details, receiving structure proposals/information, etc.)
Contact Person Title
Contact Person Email*
Claimant Name
Claimant DOB
MM slash DD slash YYYY
Gross Settlement Amount*
**If no settlement has occurred or you are unsure, indicate gross settlement amount as $0.00
Net to Client (Structure Amount)*
(Amount being placed into structured settlement annuity- can be exact amount (after fees, costs, liens, etc.) OR estimated amount. **If no settlement has occurred or you are unsure, indicate amount as $0.00)
Select any/all that apply*
- All liens have been finalized (Private, Medicaid, Medicare, ERISA)
- Wish to outsource lien resolution
- Case has settled
- Settlement check remains with defendant/insurance carrier
- Client currently receives (or is applying for) SSI and/or Medicaid
- Client currently receives (or is applying for) SSDI and/or Medicare
- Client is disabled
- None of the above
Name
This field is for validation purposes and should be left unchanged.

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