Cash Advance Request All Information Is Strictly Confidential * Indicates required fields. Please note that we do not fund cases where the injuries occurred in the states of: Missouri, North Carolina, Nevada or Maine. 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! Username * Password: * Password (again): *   Title Please Select Mr. Mrs. Ms. Dr. First Name * Last Name * Address | Apt/Suite * City * State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming * (If non-U.S. state, please specify) Zip Code * Phone Number () - * Alternate Phone Number () - Email Address * Advance Amount Requested: $ * Firm Name * Attorney's Name * Name of Paralegal or Assistant Address | Suite City State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming (If non-U.S. state, please specify) Zip Code Phone Number () - * Fax Number () - Email Address Date of Incident / /   (mm/dd/yyyy) Location of Incident City State Do we fund your state? Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming * (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 * Dear *, I hereby authorize and direct you to release to a representative of Injury Funds, 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: * *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.

NOTE: The term "loan" or "loans," where used to describe lawsuit funding is not an accurate legal or financial definition of the transaction. IT IS NOT A LOAN. The transaction is a non-recourse purchase of a portion of the proceeds of a potential future case award or settlement. A loan is a transaction that always requires repayment. Our lawsuit funding only requires repayment if the plaintiff receives a favorable cash settlement award. If the plaintiff loses their case, they do not repay anything.