application form step 2

1 Required Information*

2 Optional Information

The following information is not required but it helps us process your application as quickly as possible. Click on each of the sections below to provide the requested information. When finished, please scroll down and click the green submit button to finalize your application.

Your Information

First name:
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Last name:
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Additional Attorney Information

First name:
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Attorney/Paralegal Email Address:
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City:
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Law Firm Contact (Paralegal/Legal Assistant):
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Have you ever been injured in an incident or accident prior to this case?
  • - select a option -
  • Yes
  • No
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Last name:
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Fax Number:
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State:
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
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Additional Case Information


Name(s) of Defendant(s)
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Describe the treatments you have received and are receiving for your injuries:
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What is the status of the case (e.g. not filed, filed, settled, settlement offer made)?
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If you were working at the time of the incident, accident or injury, how much time did you miss from work because of the incident, accident, or injury?
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Is the attorney or law firm handling more than one accident case for you?
  • - select a option -
  • Yes
  • No
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Did you receive an advance from another funding company on this or any other case?
  • - select a option -
  • Yes
  • No
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Are there any outstanding liens against you and/or the case? (medical, hospital, workman's comp, disability, IRS, etc.)
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Have you now or ever filed for bankruptcy?
  • - select a option -
  • Yes
  • No
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Additional Funding Information

I need these funds for:
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Please provide funding via
  • - select a option -
  • Prepaid Debit Card
  • Check
  • Western Union-Store Pickup
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