Quick Application

All fields are required, except those marked with *

Event Date: Client Name: Email Address: Advance Amount Requested: Address: City: State:

We are not allowed to fund any Ohio Cases

Zip: Phone Number: * Cell Phone Number:

Type: Describe what happened? If any, what injuries did you sustain?

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Event Date:
Client Name:
Email Address:
Advance Request:
Address:
City:
State:	*We are not allowed to fund any Ohio Cases*
Zip:
Phone Number:
* Cell Phone Number:
Work Phone Number:
Social Security Number
* Birth Date:
Employer:
Occupation:
Annual income:

Type:
Describe what happened?
Location (city, county) of incident:

Describe your injury:
Did you go to the hospital in an ambulance?	Yes No
If not, when did you go?:
Were you admitted to the hospital?	Yes No
How long did you stay?:
Did you require surgery?	Yes No
Total medical bills:
Total hospital bills:
Total lost wages
Have you ever been bankrupt?	Yes No
Have you accepted any other advances on this case? If so, please describe the amount due.

Were you ticketed?:	Yes No
Was defendant ticketed?:	Yes No
Your insurance company:
Defendant's insurance company:
Did defendant's insurance company pay for your vehicle damage?:	Yes No
Vehicle damage:
Describe Medical Treatments:
MRI:	Yes No
Surgery:	Yes No
Fractures:	Yes No
Still Treating:	Yes No
Who is Paying Medical Bills: