Lawsuit Loan Application

get lawsuit loan - cash for your lawsuit in 7 days or less

Instructions: Please complete this application to the best of your ability. If you do not know the answer to a question, just move on. We can obtain the answers from you or your attorney at a later time. It is more important to get the application submitted to us than to worry about each specific question. If you have any questions please contact us.

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

First Name*

First Name*

Last Name*

Last Name*

E-mail Address*

E-mail Address*

Street Address

City

State/Prov

Zip/Postal Code

Home Phone*

Home Phone*

Fax

Amount of Money Requested

Attorney Name*

Attorney Name*

Attorney Law Firm

Attorney Address, City, State, & Zip

Attorney Phone*

Attorney Phone*

Attorney Fax

Attorney Email

Attorney Website

Assistant to Attorney

City/County and State of Lawsuit

Case Name, if you know

Name of Defendant (who you are suing)

Type of Lawsuit (type of case):

Date of Accident / Incident:

Case Details, explain your case:

Did you have surgery?

	Yes
	No

What are your injuries?

What are your medical costs to date?

Did you have any wages lost due to accident?

	Yes
	No

If yes, how much are your lost wages?

Have you returned to work?

	Yes
	No

What was your occupation at the time of the accident?

Have you had any other loans, liens, or advances on this case?

	Yes
	No

If yes, how much and what type of lien?

May we contact your Attorney?

	Yes
	No

How did you learn of us?

Referral Agent Name

Referral Phone Number or Email

This application is also available via: phone, fax, email, and even traditional mail. Please contact us if you wish to complete the application other than online.

Note: There is also some information not on the above application that we will need if we are to close a Lawsuit Loan for you. This includes your date of birth, social security number, and a copy of your driver's license. We will not use this information to run your credit. This information is used to verify your identity (a post September 11th requirement) and to make sure there are no liens against your legal claim which would prevent us from funding you. Examples of liens which can hurt your funding are: child support liens, an open bankruptcy, and IRS or state tax liens. And in order to protect your privacy and trust we will only ask for this very personal information when we are close to completing your funding request.

* See our Lawsuit Loan Disclaimers & Clarifications

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