Advanced Lawsuit Funding - lawsuit pre-settlement funding application

Your accuracy in filling out the Online Application will expedite the approval process. Include as much of the information as you have available. BY SUBMITTING THIS FORM YOU AGREE THAT ALL THE INFORMATION LISTED IS ACCURATE TO THE BEST OF YOUR KNOWLEDGE.

First Name:
*
Last Name:
*
Date of Birth
Email Address:
Address:
*
City:
*
State:
*
Zip Code:
*
Home Phone:
*
Work Phone:
Cell Phone:
Other:

Attorney Information
Lawfirm Name:
Lawyer's Name
*
Lawyers Address
City :
State :
Zip Code :
Phone:
Fax :

Case Information
Any prior accidents?

Any prior lawsuits?

Prior funding?

Date of accident or injury:
Name of defendants:
Summarize basis for lawsuit:
Summarize injuries:
Summarize treatment:

sprain / strain
soft tissue
fracture without surgery
fracture with surgery
brain injury
other surgery
other
Were you employed when accident happened?

If (yes) have you missed time?
Do you have more than 1 pending lawsuit?

If (yes) explain:
Did you receive cash from another funding company on this case or any other?

If (yes) explain:
Any outstanding liens on your lawsuit?

If (yes) explain:
Ever declare bankruptcy?

If (yes) explain:

Funding Request
Amount of funding requested:
Reason for funds:
How did you find us?

By submitting this form I agree that all the information is true and accurate.

I REQUEST AND AUTHORIZE MY ATTORNEY TO PROVIDE Advanced Lawsuit Funding Inc. with whatever information (whether oral or written) needed to evaluate my funding request. I specifically waive any privilege that I may have regarding such information.

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