PAPERLESS ONBOARDING APP

Name: Abacus Settlements
Address: 2101 Park Center Drive Suite #170,, Orlando, FL, 32835
Telephone: 800-561-4148

Paperless Online Application

Progress

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INSTRUCTIONS

Our online eSign Intake Form instantly provides us with the information and authorization we need to do full underwriting and pricing on your settlement case. Please fill out the form fields to the best of your ability. Once complete, you will receive an email with eSign digital signature instructions. You can use your computer or tablet to sign our forms online instantly. Please call us at 800-561-4148 with questions. All information is kept secure.

Insured - First Name *

Insured - Last Name *

Insured - Date of Birth *

(MM/DD/YYYY). Required for eSign and HIPAA.

Insured - Social Security

Required for eSign and HIPAA.

Insured - Address

Insured- Phone

Insured - Email Address *

Required to recieve HIPAA doucments via email.

Do You Have a Second Person Insured on Your Policy?

Yes