Personal Information

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: $ *


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


Case Description

Date of Incident / /
  (mm/dd/yyyy)
Location of Incident
City
State
Do we fund your state?
*
(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
Life Insurance Claim
Maritime/Seaman's Claim (Jones Act)
Medical Malpractice
Motorcycle or Bicycle Accident
Nursing Home Neglect
Premises Liability (Slip & Fall)
Product Liability
Property Insurance Claim
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 *


Authorization for Release of Information

Dear *,

I hereby authorize and direct you to release to a representative of Alliance Claim Funding, any portion of my file related to your representation of me, for my injuries sustained in the incident of *.

I acknowledge that I understand the benefits of non-recourse funding. I further acknowledge I understand the effects of disclosing the contents of my file, including waiver of the attorney-client and work product privileges.

Thank you in advance for you cooperation.

Sincerely,

*
DATE: *(mm/dd/yyyy)

*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.