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 PRE-SETTLEMENT LAWSUIT
 Funding Application

Plaintiff/Claimant Information

  Claimants (Plaintiffs)    
  First Name  
  Middle Name  
  Last Name  
  Address  
  Address Line 2  
  City  
  State  
  Zip  
       
  Home Phone  
  Work Phone  
  Cell Phone  
  Fax  
  Email Address  
       
  Gender Male    Female  
       
  Occupation  
       
  Currently Employed ? Yes    No  
       
  Amount Requested $  
       

Attorney Information

  Law Firm’s Name  
  Attorney Handling Case  
  Address  
  Address Line 2  
  City  
  State  
  Zip  
  Phone  
  Fax  
  Email Address  
  Website Address  
       
  Attorney Fee (Settlement) %

(Trial)%  
       
  Attorney of Record
On Case		  
       
  Co-Council (if any)  
       
       

Incident Information

  Defendant(s)  
       
  Date of Accident  
  County  
  State  
       
  Type Motor Vehicle   Slip&Fall   Worker’s Comp.
Assault   Maritime (Jones Act)  Medical Malpractice
Other Type injury 		 
       
  Brief Description
of Incident