BEGIN APPLICATION

Date: mm/dd/yy

Application Prepared By:

Relationship to Plaintiff:

Case Status: ("Before Settlement", "After Settlement" or "Appeal")

Has Funding Been Applied For Elsewhere- Yes/No:

If Yes What Was The Outcome:

Funding Amount:

CLIENT INFORMATION

Plaintiff Name:

Address:

City, State, Zip:

Home Phone:

Cell Phone:

DOB:

SS#:

Work Phone:

Email Address or Fax #: (We send documents to sign)

Amount Requested:

Are You In Bankruptcy Currently?:

ATTORNEY INFORMATION

Attorney Name:

Firm Name:

Address:

City, State, Zip:

Phone:

Fax:( Very Important)

Email:

Primary Contact:

Phone:

LAWSUIT INFORMATION

Date of Incident:

City & State:

Case Type: (Auto, WC, Product Liability, Commercial etc.)

Description of Damages:

Property Damages:

Theory of Liability:

Demanded Settlement Amount:

Est. Months Until Settlement:

Liens on Case:

For How Much?

Settlement Offer Amount:

Estimated Trial Date:

Is Case On Appeal?:

Verdict Amount:

Defendant(s) Insurance Company Name:

Insurance Coverage Amount:

Which Search Engine Did You Use To Find Us:

What Search Term Did You Use To Find Us:

FOR PERSONAL INJURY PLEASE COMPLETE THE FOLLOWING

Medical Treatment(s):

Medical Bills to Date:

Are Medical Bills Paid?

Medical Bills Paid By Whom?:

Est. Lost Wages:

Est. W/C Lien Amount: