Litigation

Step 2 -Applicant Information (Plaintiff)

Applicant Name*

First Last

Cell Phone*

One-Time Password*

Password verified.

Applicant's Home Address*

Applicant DOB*

Applicant's Email Address*

Step 3 - Case Details

Case Type*

Date Occurred*

Location of Incident

Property Damage?

Represented by an attorney?*

Lawsuit been filed?

Venue?

SeaCoast Financial will NOT fund inactive cases or cases without active Attorney representation.

Was another party at fault?

Filed a claim yet?

Role in Incident?

Incident Location

Is there Medpay?

Medpay Amount?

Adjuster

UM / UIM Insurance Name

UM / UIM Policy Limits

Hazard (e.g., wet floor, broken steps) Reported Prior?

Who was the medical provider involved?

Nature of Malpractice

Dog know to be aggessive?

Dog leashed or in fenced area?

Relation to the deceased

What event led to the wrongful death claim?

Injured on the job?

Filed Workers compensation claim?

Machinery or equipment involved?

Brief Description of the Incident

Taken to hospital?

Type of Injuries Sustained

Treatments Received*

Please Specify:*

Ongoing medical treatment?

Police Report?

If yes, provide the report number and agency.

Uploading a claim form IS NOT sufficient proof of a settlement offer or active negotiations.

File Uploads

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB, 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 possible

Step 4 - Additional Information

Do you have personal insurance coverage?

List any other insurance involved.

Unable to work due to the injury?

Number of Missed Work Days

Monthly income before the accident:

Step 5 - Attorney & Defendant Information

If you fail to provide complete and accurate Attorney Contact or Case ID Information as requested, your application will be deemed incomplete and automatically rejected, with no further communication from SeaCoast Financial, LLC. Additionally, uploading a claim form is not valid proof of a settlement offer or negotiations.

Attorney Firm*

Firm NameAttorney NamePhone NoEmail

Attorney Case ID*

Referral Source*

Attorney Firm*

Attorney Name*

Defendant Name(s)

Insurance Company

Policy Limits

Claim #

Liability Accepted?*

Step 6 - Loan Details

Requested Loan Amount*

Estimated Value of Case*

Prior Funding on this Case?*

Negotiations Status

Settlement Prospects

Months Until Settlement*

Any settlement offers?*

Offered Amount*

(Most Recent Offer)

Use of Proceeds?

Select all aplicable

Medical

Housing

Living expenses

Legal

Other (Please specify):

Please specify

Any Liens?*

Lienholder / interest holder

Amount of Lien / subrogation

Is lien or interest an ERISA plan?

Step 7 - Miscellaneous

Any Notes, Comments or Questions?

Application ID