Client Online Application

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Lawsuit Funding

Event Date
Client Name
Email Address
Advance Request
Address
City
State
Zip
Phone
Cell
Work
Social security Number
Birth Date
Employer
Occupation
Annual Income
Event Description
Type
Describe what happened
Location (city, county) of incident
Damages
Describe your injury
Did you go to the hospital?	yes no
When did you go?
Were you admitted to the hospital?	yes no
How long did you stay?
Did you require surgery?	yes no
Total lost wages
Have you ever been bankrupt	yes no
Have you ever accepted any other advances on this case? If so, please describe the amount due.
Liability
Were you ticketed?	yes no
Was defendant ticketed?	yes no
Your insurance company
Defendant’s insurance company
Did defendant’s insurance company pay for 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?
Attorney
Your Attorney’s Name
Firm
Address
City
State
Zip
Telephone
Fax
Case Name
Case Number

First Name
Last Name
Email
Case Type
Phone #
Cell #
State

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