Lawsuit Pre-Settlement Funding - Full Application

Your Contact Information

* = Required Information

*Last Name:

*First Name:

Address:

City:

State: State AL AR AK AZ CA CO CT DC DE FL GA DE HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY            Zip:

*Advance Requested (Min $500):

Work Phone:

Home Phone:

Cell Phone:

*Email:

Do you already have a loan against your settlement?  Yes No

If yes, what is the approximate current payoff amount? 

Attorney Contact Information

Attorney Name:

Address 1:

Address 2:

City:

State: State AL AR AK AZ CA CO CT DC DE FL GA DE HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY             Zip:

Name of Law Firm:

Attorney Phone:

Attorney Fax:

Paralegal Name:

Lawsuit Description

Type of Case:

Select Bextra Zyprexa Ceiling Collapse Commercial Construction Accident Defective Product Dog Bite Maritime Claim (Jones Act) Medical Malpractice Motor Vehicle Accident Nursing Home Negligence Police Brutality Product Liability Railroad Claim (FELA) Slip/Trip and Fall Sexual Harassment Worker's Compensation Wrongful Death Wrongful Termination Wrongful Discrimination Other

Date of Incident (mm/dd/yyyy):

Please Describe Incident:

Please Describe Injuries / Damages:

For personal injuries, describe strains, sprains, surgeries, fractures, etc.

Comments or Questions: