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Please note that we do not fund cases where the injuries occurred in the states of: Arkansas, Colorado, Illinois, Kansas, Louisiana, Maine, Maryland, Missouri, Nevada, North Carolina, Ohio, Oklahoma, Rhode Island, Tennessee or Texas. Also we do not fund workers compensation cases in any state. However, if you have a 3rd party case related to your worker's comp case, then we may be able to assist so please apply!


1 Personal Information

Username
*

Password:
*

Password (again):
*

Title

First Name
*

Last Name
*

Address | Apt/Suite
*

City
*

State
*
(If non-U.S. state, please specify)

Zip Code
*

Phone Number
() - *

Alternate Phone Number
() -

Email Address
*

Advance Amount Requested:
$ *

2 Attorney's Information

Firm Name
*

Attorney's Name
*

Name of Paralegal or Assistant

Address | Suite

City

State

(If non-U.S. state, please specify)

Zip Code

Phone Number
() - *

Fax Number
() -

Email Address

3 Case Description

Date of Incident
/ /
(mm/dd/yyyy)

Location of Incident

City
*
(If non-U.S. state, please specify)

Type of Incident * (Is my case eligible?)

Airplane Accident
Appeal
Assault
Automobile Accident
Boating Accident
Breach of Contract
Burn Injury
Construction Accident   
Disability Insurance Claim
Dog Bite
Maritime/Seaman's Claim (Jones Act)
Medical Malpractice
Motorcycle or Bicycle Accident
Nursing Home Neglect
Premises Liability (Slip & Fall)
Product Liability
Railroad Claim (FELA)
Wrongful Death

Describe the Incident

Type of Injury * (Do my injuries qualify?)

Amputation
Death
Fractures
Herniated Disks   
Loss of Vision
Paralysis
RSD
Significant Scarring
Surgery
Any other serious injuries

Describe your Injuries

Did you go to the Emergency Room?
Yes   No

Lawsuit Filed?
Yes   No *

Are you currently or have you ever been involved in a bankruptcy proceeding?
Yes   No

If yes, please explain:

Have you ever been convicted of a crime?
Yes   No

If yes, please explain:

*By clicking here you indicate that you have read and agree to the Authorization for Release of Information. You must check this box to have your application processed. This gives us permission to contact your attorney and review your file. All information is held strictly confidential.

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