Litigation Funding
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Your Contact Information
*First Name:
*Last 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:
*Cash Advance Amount Requested (Min $500):
Work Phone:
Home Phone:
Cell Phone:
*Email:
Do you already have a loan against your future settlement?
Yes No
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.
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Jones Act
Cash Advance: Apply
Funding Process
