Test Test Plaintiff Application (FULL)

1. Plaintiff Information

Amount of Funding Requested *

Full Name of Claimant *

Address

City

State *

Zip/Postal

Date of Birth *

Phone Number *

Email *

Social Security Number

2. Case Information

Any prior funding?

Yes

No

Prior funding company name

Date of prior funding

Prior funded amount

Date of Accident

What type of case? *

Any Injuries or Surgery?

Description of Accident

Documents Provided

Accident/Police Report

Medical - ER | MRI | Operative | Experts Report

Bill of Particulars

Summons & Complaint

Upload Documents

Maximum upload size: 52.43MB

Policy Limits

Insurance Company or Self-Insured:

3. Funding Contract Information

Contract Execution Type *

Fax

Email

E-Signature

E-Signature Type

E-Signature Client & Attorney

E-Signature Client Only

E-Signature Attorney Only

Client E-signature Info (Email or Smartphone Cell #):

Attorney E-signature Info (Email or Smartphone Cell #)

Funding Preference

Check

Western Union

Wire Transfer

4. Attorney/Firm Information

Attorney Name

Attorney Email

Case Contact Name

Case Contact Email

Law Firm Name

Firm Address

Firm City

Firm State *

Firm Postal/Zip

Law Firm Phone

Law Firm Fax

Long Application from PDF

1. Plaintiff Information

2. Case Information

3. Funding Contract Information

4. Attorney/Firm Information

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