Maritime Jones Act Pre-Settlement Funding - Full Application

Don't have all the information available?  Just fill out as much as you can.  Alternatively, you can submit the short application and we will follow up with you as soon as possible.  We understand the need for speed!

Your Contact Information

* = Required Information

*Last Name:

*First Name:

Address:

City:

State:            Zip:

 

*Advance Requested:

Work Phone:

Home Phone:

Cell Phone:

*Email:

Normal Occupation:

Employed? 

Attorney Contact Information

Attorney Name:

Address 1:

Address 2:

City:

State:             Zip:

Name of Law Firm:

Attorney Phone:

Attorney Fax:

Paralegal Name:

Incident Description

Type of Case:

 

Date of Incident (mm/dd/yyyy):

 

Please Describe Incident:

Please Describe Injuries

Include strains, sprains, disk problems, surgeries, fractures, burns, etc.

 

Comments or Questions:
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Short Application

First Name

Last Name

Email

 

Phone

Best time to call

Type of Case

Amount Requested

Comments