Gallagher Actuarial Services

Application for Simplified Actuarial Valuation

This form may be used to request an actuarial valuation of a scheme of periodic payments. Please complete all of the boxes and check the appropriate buttons, then "Submit" the form. If any required information is missing, you will be contacted via the selected "Preferred method of contact". The charge for the valuation is $50.00. Before submitting the application, you can be connected to a secure site for payment through a credit card or bank account by clicking on the logo button at the bottom of the page (PayPal.com). (You will be returned to this page after the payment process!) If the payment process is not completed, you may follow-up by sending a check to the address at the bottom of this page. If no credit card payment is approved, and no check is received within 7 days of the submission of the Application, the submission will be purged and no response will be made. Gallagher Actuarial Services reserves the right to apply the application fee toward ½ hour of professional review and consultation in the event that the Application is incomplete or it is deemed inappropriate to apply simplified actuarial valuation techniques to the described situation.

If you'd rather fill in a printed application and send it by USPS or FAX, click here for a printable text version of this form.

Name of Requester:

Firm/Address:

Telephone number:

FAX number:

E-mail address:

Preferred method of contact:

Telephone FAX E-mail USPS to Firm/Address

Payee Information:

Name:

Date of Birth:

Sex:

Male Female

Health Status:

Generally Healthy
Disabled (Nature of Disability:

Payment Information:

Payer:

Purpose of Payment:

Retirement Disability Negotiated Settlement
Other (Please Describe:

Amount of Payment: $

Commencement Date:

Frequency:

Weekly Monthly Annually

Effect of Inflation:

Automatic COLA is not is applicable
(Annual CPI adjustments assumed effective after 1 year of payments if applicable.)

Form of Payment:

Lifetime of Payee
Lifetime of Payee with % continuation for lifetime of surviving Beneficiary after the death of Payee
Lifetime of Payee and Beneficiary with % continuation for lifetime of either survivor after the first death
Other (Please Describe:
Special Considerations:
Payments are guaranteed through:
No payments will be made after:

Beneficiary Information:

Name:

Date of Birth:

Sex:

Male Female

Health Status:

Generally Healthy
Disabled (Nature of Disability:

Requested Valuation Date:

You might want to print this page before you submit it!
If there is something especially complicated about these payments that you feel is not explained by the above entries, please send a separate e-mail explaining the situation or use another contact method below.

RETURN TO MAIN

RETURN TO VALUATION COMMENTS

Michael E. Gallagher
d/b/a Gallagher Actuarial Services
P.O. Box 297
Sebago, ME 04029-0297
(207) 650-6405
email: actuary "at" galactser.com
World Wide Web URL:
http://www.galactser.com/
This page: ../form.htm

Copyright © 2015 Gallagher Actuarial Services. All rights reserved.