Lawsuit Funding Request Form

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Lawsuit Funding Request Form

Request Lawsuit Funding Here

Your lawsuit funding request form is here. Now that you have discovered how critical lawsuit funding has become to the lawsuit process, you will need to complete a lawsuit funding request form to obtain it.

Lawsuit Funding provides the necessary funds plaintiffs and attorneys need to continue their case. But, you must know where to go to receive adequate funding. Any reputable lawsuit funding company providing serious lawsuit advances will require that you provide a wealth of information up-front about your case. This will enable the firm to make a quicker, more comprehensive funding decision.

This is the thought process behind the Lawsuit Funding Request Form you see below. Yes, this form is relatively long...and...yes, it asks for a great deal of information.

This is very intentional.

This lawsuit funding request form is intended only for those who are serious about acquiring a substantial amount of funding. It is not designed for the simply curious, nor for those seeking mere "pocket change".

So, if you are serious about obtaining lawsuit funding, please complete the form below, as thoroughly as you can. Then, SUBMIT it. Do not delay sending the form due to not knowing a few of the requested elements. For you, time is more critical than completeness at this point. Submit the form immediately, and we can get the missing information from you later.

We are very serious about helping you as much as we can and will do everything humanly possible to satisfy your request for a lawsuit advance. We are very successful in fulfilling our clients' needs.

(Also, please know that we hate spam as much as you do. So, rest assured that we will keep all your information confidential and strictly in-house. We have never - and will never - release your information to any other individual, agency or organization outside our lawsuit funding approval organization.)

For a lawsuit advance, please complete and submit the lawsuit funding request form below.

Lawsuit Funding Request Form

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Home Phone*
Home Phone*

E-mail Address

Business Phone

Fax

Cellular Phone

Gender*
Gender*

	Male
	Female

Victim's Name (...if other than above)*
Victim's Name (...if other than above)*

Date of Birth*
Date of Birth*

Occupation*
Occupation*

Currently Employed*
Currently Employed*

	Yes
	No

Social Security Number*
Social Security Number*

Amount of Advance Requested ($)

Have You Obtained Previous Funding?

	Yes
	No

Do You Have An Attorney?*
Do You Have An Attorney?*

	Yes
	No

If Yes, Name of Law Firm*
If Yes, Name of Law Firm*

Attorney's Name*
Attorney's Name*

Attorney's Phone Number*
Attorney's Phone Number*

Law Firm Receptionist (If Known)

Legal Assistant (If Known)

Law Firm Address (City, State, Zip)*
Law Firm Address (City, State, Zip)*

Law Firm (Telephone #)

Law Firm (Fax #)

Law Firm E-Mail Address

Law Firm Website

Attorney Fee % (For Settlement)

Attorney Fee % (For Trial)

Attorney of Record on Case?

	Yes
	No

Co Council?

Defendants

Date of Event*
Date of Event*

County and State of Event

Type of Case*
Type of Case*

	Auto Related
	Drug Related
	Product Liability
	Wrongful Death
	Construction Related
	Medical Malpactice
	Workers Compensation
	Slip & Fall
	Maritime (Jones Act)
	Other

Description of Incident*
Description of Incident*

Description of Damages

Any Surgeries?

Defendant Cited?

	Yes
	No
	N/A

If Not, Theory of Liability

Defendant Impaired By Alcohol or Drugs?

	Yes
	No

Plaintiff Impaired By Alcohol or Drugs?

	Yes
	No

Medical Costs: Non-Diagnostic ($)

Medical Liens ($)

MRIs, CAT Scans, X-rays, etc ($)

Chiropractor/Physical Therapy ($)

Future Medical Costs ($)

Any Property Damage ($)

Any Punitive Damages ($)

Lost Wages, To Date ($)

Lost Wages, Future ($)

Any Worker's Compensation Leins ($)

Demand Letter ($)

Settlement Offer? ($)

Probable Settlement Range ($ to $)

Probable Verdict Range ($ to $)

Settlement Conference Date?

Arbitration Date?

Estimated Trial Date?

Estimated Closure Date?

3rd Party Insurance Company? (Name, Address, Phone)

PolicyType, Policy Limit, Case #

1st Party Insurance Company? (Name, Address, Phone)

PolicyType, Policy Limit, Case #

How Much Money Are Your Applying For? ($ Advance)*
How Much Money Are Your Applying For? ($ Advance)*

What Is The Use of Funds?*
What Is The Use of Funds?*

Please enter the word that you see below.

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Lawsuit Funding Request Form

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