Claimant Name
*
First Name
Last Name
Your Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
*
-
Area Code
Phone Number
Exact Name of Funding Party
*
How will the account be funded?
*
Lump Sum
Annuity
Not sure at this time
Will AIMS have any reversionary interest?
*
Yes
No
Not sure at this time
Will CMS approval be obtained?
*
Yes
No
Not sure at this time
Enrollment package should be sent to (list email addresses):
Attach copy of MSA Report and CMS approval if obtained
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