Litigation Funding (1) "*" indicates required fields Applicant Information (Plantiff)Applicant Name* First Last Applicant's Home Address Street Address Address Line 2 City ZIP Code Cell Phone*Applicant DOB* MM slash DD slash YYYY Applicant's Email Address* Case DetailsCase Type*Auto AccidentAssault & BatteryDefective DrugsDog BiteEmploymentFELAJones ActLabor ActLabor LawMedical MalpracticeProduct LiabilityPremises LiabilityPolice BrutalitySlip & FallSettledWhistleblowerWorker's CompensationWorker's Compensation - Non-SubscriberWork InjuryWrongful DeathOtherDate Incident Occurred* MM slash DD slash YYYY Location of IncidentProperty Damage?SELECTYESNOAre you represented by an attorney?*SELECTYESNOLawsuit been filed?SELECTYESNOVenue?Was another party at fault?SELECTYESNOFiled a claim yet?SELECTYESNORole in Incident?SELECTDRIVERPASSENGERPEDESTRIANIncident LocationSELECTPRIVATE RESIDENCEBUSINESSIs there Medpay?SELECTYESNOMedpay Amount?AdjusterUM / UIM Insurance NameUM / UIM Policy LimitsHazard (e.g., wet floor, broken steps) Reported Prior?SELECTYESNOWho was the medical provider involved?Nature of MalpracticeSELECTMISDIAGNOSISSURGICAL ERRORDog know to be aggessive?SELECTYESNODog leashed or in fenced area?SELECTYESNORelation to the deceasedWhat event led to the wrongful death claim?Injured on the job?SELECTYESNOFiled Workers compensation claim?SELECTYESNOMachinery or equipment involved?SELECTYESNOBrief Description of the IncidentApplicant taken to the hospital?SELECTYESNOType of Injuries Sustained ER VIA AMBULANCE SOFT TISSUE ONLY MRI SCAN FRACTURE / BROKEN BONE(S) BULGE / HERNIATION PT / CHIRO PRIOR INJURIES SURGERY COMPLETED KNEE INJURY SHOULDER INJURY NECK INJURY BACK INJURY OTHER (PLEASE SPECIFY) Please Specify:*Any Treatments Received?*SELECTFRACTURE / BROKEN BONESINJECTIONSMRINONE / NAPT / CHIROPRACTORSOFT TISSUE ONLYSURGERY(IES)OTHEROngoing medical treatment?SELECTYESNOReported to the police or other authority?SELECTYESNOIf yes, provide the report number and agency.File Uploads Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 10. Upload any police / incident report and all files and supporting documentation in support of settlement funding.Describe the case as clearly and succinctly as possibleAdditional InformationDo you have personal insurance coverage?SELECTYESNOList any other insurance involved.Are you unable to work due to the injury?SELECTYESNOHow many days of work have you missed?Monthly income before the accident:Attorney & Defendant InformationAttorney Firm*Attorney Name*Attorney Case ID*Attorney Website* Attorney Phone*Referral Source*SelectAttorney RefferalFriendLawyers.comOnline Search Engine (Google, Bing or Yahoo)Print AdvertisementRadio AdvertisementTV AdvertisementOtherDefendant Name(s)Defendant's Insurance CompanyDefendant's Policy LimitsClaim #Has Liability been Accepted?*NOYESLoan DetailsRequested Loan Amount*Estimated Value of Case*Prior Funding on this Case?*NOYESNegotiations StatusSELECTNEGOTIATIONSTRIAL PREPARATIONSettlement ProspectsMonths Until Settlement*6 Months12 Months18 Months24 Months30 Months36 MonthsAny settlement offers made?*SELECTYESNO(Most Recent) Offered Amount*Use of Proceeds?Select all aplicable Medical bills Rent or mortgage payments Day-to-day living expenses Legal fees Other (Please specify): Please specifyAny Liens?*SELECTYESNOLienholder / interest holderAmount of Lien / subrogationIs lien or interest an ERISA plan?SELECTYESNOMiscellaneousAny Notes, Comments or Questions?Consent and Authorization* I AGREEI authorize the loan provider to contact my attorney for case-related information and to verify the details of my claim. I understand that this application form is for the sole purpose of assessing eligibility for a pre-settlement loan and that completing it does not guarantee approval. By providing my phone number, I agree and acknowledge that Litigation Funding Co or SeaCoast Financial, LLC may send text messages to my wireless phone number for communication regarding my application. Standard message and data rates may apply. Message frequency will vary, and I may opt out at any time by replying "STOP." For more information on how my data will be handled, please visit https://litigationfunding.co/privacy-policy. Litigation Funding (1) "*" indicates required fields Applicant Information (Plantiff)Applicant Name* First Last Applicant's Home Address Street Address Address Line 2 City ZIP Code Cell Phone*Applicant DOB* MM slash DD slash YYYY Applicant's Email Address* Case DetailsCase Type*Auto AccidentAssault & BatteryDefective DrugsDog BiteEmploymentFELAJones ActLabor ActLabor LawMedical MalpracticeProduct LiabilityPremises LiabilityPolice BrutalitySlip & FallSettledWhistleblowerWorker's CompensationWorker's Compensation – Non-SubscriberWork InjuryWrongful DeathOtherDate Incident Occurred* MM slash DD slash YYYY Location of IncidentProperty Damage?SELECTYESNOAre you represented by an attorney?*SELECTYESNOLawsuit been filed?SELECTYESNOVenue?Was another party at fault?SELECTYESNOFiled a claim yet?SELECTYESNORole in Incident?SELECTDRIVERPASSENGERPEDESTRIANIncident LocationSELECTPRIVATE RESIDENCEBUSINESSIs there Medpay?SELECTYESNOMedpay Amount?AdjusterUM / UIM Insurance NameUM / UIM Policy LimitsHazard (e.g., wet floor, broken steps) Reported Prior?SELECTYESNOWho was the medical provider involved?Nature of MalpracticeSELECTMISDIAGNOSISSURGICAL ERRORDog know to be aggessive?SELECTYESNODog leashed or in fenced area?SELECTYESNORelation to the deceasedWhat event led to the wrongful death claim?Injured on the job?SELECTYESNOFiled Workers compensation claim?SELECTYESNOMachinery or equipment involved?SELECTYESNOBrief Description of the IncidentApplicant taken to the hospital?SELECTYESNOType of Injuries Sustained ER VIA AMBULANCE SOFT TISSUE ONLY MRI SCAN FRACTURE / BROKEN BONE(S) BULGE / HERNIATION PT / CHIRO PRIOR INJURIES SURGERY COMPLETED KNEE INJURY SHOULDER INJURY NECK INJURY BACK INJURY OTHER (PLEASE SPECIFY) Please Specify:*Any Treatments Received?*SELECTFRACTURE / BROKEN BONESINJECTIONSMRINONE / NAPT / CHIROPRACTORSOFT TISSUE ONLYSURGERY(IES)OTHEROngoing medical treatment?SELECTYESNOReported to the police or other authority?SELECTYESNOIf yes, provide the report number and agency.File Uploads Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 10. Upload any police / incident report and all files and supporting documentation in support of settlement funding.Describe the case as clearly and succinctly as possibleAdditional InformationDo you have personal insurance coverage?SELECTYESNOList any other insurance involved.Are you unable to work due to the injury?SELECTYESNOHow many days of work have you missed?Monthly income before the accident:Attorney & Defendant InformationAttorney Firm*Attorney Name*Attorney Case ID*Attorney Website* Attorney Phone*Referral Source*SelectAttorney RefferalFriendLawyers.comOnline Search Engine (Google, Bing or Yahoo)Print AdvertisementRadio AdvertisementTV AdvertisementOtherDefendant Name(s)Defendant's Insurance CompanyDefendant's Policy LimitsClaim #Has Liability been Accepted?*NOYESLoan DetailsRequested Loan Amount*Estimated Value of Case*Prior Funding on this Case?*NOYESNegotiations StatusSELECTNEGOTIATIONSTRIAL PREPARATIONSettlement ProspectsMonths Until Settlement*6 Months12 Months18 Months24 Months30 Months36 MonthsAny settlement offers made?*SELECTYESNO(Most Recent) Offered Amount*Use of Proceeds?Select all aplicable Medical bills Rent or mortgage payments Day-to-day living expenses Legal fees Other (Please specify): Please specifyAny Liens?*SELECTYESNOLienholder / interest holderAmount of Lien / subrogationIs lien or interest an ERISA plan?SELECTYESNOMiscellaneousAny Notes, Comments or Questions?Consent and Authorization* I AGREEI authorize the loan provider to contact my attorney for case-related information and to verify the details of my claim. I understand that this application form is for the sole purpose of assessing eligibility for a pre-settlement loan and that completing it does not guarantee approval. By providing my phone number, I agree and acknowledge that Litigation Funding Co or SeaCoast Financial, LLC may send text messages to my wireless phone number for communication regarding my application. Standard message and data rates may apply. Message frequency will vary, and I may opt out at any time by replying “STOP.” For more information on how my data will be handled, please visit https://litigationfunding.co/privacy-policy.
