Litigation Funding

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

*First Name:

*Last Name:

Address:

City:

State:

Zip:

 

*Cash Advance Amount Requested (Min $500):

Work Phone:

Home Phone:

Cell Phone:

*Email:

Do you already have a loan against your future settlement?

 

If yes, what is the approximate current payoff amount?

 

Attorney Contact Information

Attorney Name:

Attorney Address 1:

Attorney Address 2:

Attorney City:

Attorney State:

Attorney Zip:

 

Name of Law Firm:

Attorney Phone:

Attorney Fax:

Paralegal Name:

 

Comments or Questions:

Workers Comp Case Description

State Where Your Workers Comp Case is Filed:

 

Date of Incident (mm/dd/yyyy):

Please Describe Incident:

Please Describe Injuries / Damages: For personal injuries, describe strains, sprains, surgeries, fractures, etc.