Apply Now For Funding Call us now or complete the application below. We're here for you. OR, YOU CAN SIMPLY DOWNLOAD OUR APPLICATION HERE Select One: MVA Med Mal Legal Mal Slip and Fall Product Liability Premises Liability Wrongful Death NFL CONC Other Claimant Information Name: Social Security #: Street Address: City/State: Mobile #: Home #: Email Address: Date Of Birth: Lawsuit or Settlement Information: Lawsuit Summary: Injuries/Damages: Date Of Injury: Law Firm: Law Firm Address: Attorney Info: Attorney Phone: Attorney Fax: Paralegal Name: Policy Limit of DEF ($): Is there a Police Report? If yes, was the Def. cited? Surgery Date: Does the PL suffer from Pre-Existing Injuries? Case Filed? (YES/NO) State Case Filed In: Def, Insurance Co: PL UIM Insurance: Prior advance (loan)? If yes, Co. and Amount ($): Estimated Settlement: Pre Settlement Request ($): Attorney Email: Paralegal Email: Please send: Medical Reports (ER Records, MRI, Surgery Reports), Liability Support (Pol Rep, Copy of Complaint (if filed), if Settled, only provide Settlement Agreement / w Application completed. Thank you!