Pre-Settlement Funding Application
Legal First Name
*
Legal Last Name
*
Date of birth
*
Email
*
Phone
*
Are you working with an attorney? If yes, please enter the law firm name below.
*
Claim type:
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Auto Injury
Slip & Fall
Medical Malpractice
Worker's Comp
Wrongful Death
Civil Rights (wrongful arrests, false imprisonment, police brutality, inmate abuse)
Sexual Abuse
Others
Date of incident (mm-dd-yyyy)
*
State of residence
*
How much funding are you looking for?
Did you receive any prior funding for your case? If Yes, please enter the amount below. If No, enter 'None' below.