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Complete the following form and we will contact you within 24 hours. Click "Preview" after completing the form for a chance to preview your entries before you submit. Required fields are denoted by the symbol.
Client Information
Client’s Name
Street Address
City
State
Zip Code
Telephone (day) () -
Telephone (evening) () -
Email Address

Case Information
Date of accident/injury
Defendant Ticketed? Yes   No
Plaintiff Ticketed? Yes   No
Defendant DUI/DWI? Yes   No
Plaintiff DUI/DWI? Yes   No
Has Liability been established and/or admitted? Yes   No
Type of Incident

 Traffic Accident
Product Liabliity

Medical Malpractice
Sexual Harassment

Boating Accident
Burn Injury

Construction Accident
Dog Bite

Maritime/Seaman's Claim
Medical Malpractice

Motorcycle/Bicycle Accident
Nursing Home Neglect

Premises Liability
Product Liability

Railroad Claim (FELA)
Wrongful Death
Plaintiff's Insurance Co.
Plaintiff's Insurance Co. Street Address
Plaintiff's Insurance Co. City
Plaintiff's Insurance Co. State
Plaintiff's Insurance Co. Zip Code

Defendant Information
(Please note that we will not contact the defendant, defendant’s Attorney, or Insurance Company. This information is for our records only.)
Case Details (Provide a brief description of the facts.)
Name of Defendant
Defendant's Street Address
Defendant's City
Defendant's State
Defendant's Zip Code
Defendant's Insurance Co.
Defendant's Insurance Co. Street Address
Defendant's Insurance Co. City
Defendant's Insurance Co. State
Defendant's Insurance Co. Zip Code
Claims Representative
Claims Rep. Street Address
Claims Rep. City
Claims Rep. State
Claims Rep. Zip Code
Legal Claims Asserted
Extent of Physical and Financial Injury $
Is this case taken on a contingency basis? Yes   No
If Yes to above, what percentage?

Workers Comp Information
Employer
Insurance Company
Weekly Benefit $
No. of Weeks
Amount Paid to Date $
Weeks Remaining
Previous W/C Claim? Yes   No
Has Client Returned to Work? Yes   No
If Yes to Above, When?

Costs To Date
Current Medical $
Estimated Future Medical $
Case Expenses To Date $
Estimated Future Expenses $
Lost Wages $
Estimated Future Lost Wages $

LIENS
Medical Liens filed to date? Yes   No
Amount $
Subrogtion Claims? Yes   No
Amount $
Child Support Liens? Yes   No
Amount $
Alimony Liens? Yes   No
Amount $
Tax Liens? Yes   No
Amount $
Prior Loans/Advancements? Yes   No
Amount $
Prior Assignments? Yes   No
Amount $
Other Liens (Please Specify)
Amount $

DAMAGES
(Please note that this information will not be revealed to anyone, and we understand that you are offering no guarantees or assurances as to the validity of the case.)
What is the Estimated Value of the Case? $
Request Punitive Damages? Yes   No
Amount $
Request Compensatory Damages? Yes   No
Amount $

MEDICAL INFORMATION
Briefly Describe the Nature and Extent of the Injuries
Does Client have Preexisting Condition? Yes   No
If Yes to Above, Please Explain
Name of PCP
Ambulance Transport? Yes   No
Emergency Room Visit? Yes   No
If Yes to Above, When?
MRI? Yes   No
If Yes to Above, When?
Surgery? Yes   No
If Yes to Above, When?
Hospital Stay? Yes   No
How Many Days?
Still in Treatment? Yes   No
Briefly Describe Ongoing Treatment
Medical Costs to Date? $
Has Client Been a Defendant in Other Lawsuits? Yes   No

SETTLEMENT INFORMATION
Demand Letter Sent? Yes   No
Date Letter Sent
Amount $
Settlement Offer Made? Yes   No
Date of Offer
Amount $
Suit Filed? Yes   No
Date of Suit Filing
Mediation? Yes   No
Date of Mediation
Arbitration? Yes   No
Date of Arbitration
Judgement? Yes   No
Amount of Judgement $
Estimated Date of Settlement or Trial

 30 Days
31 - 60 Days

61 - 90 Days
91 Days - 6 Months

6 - 9 Months
9 Months - 1 Year

1 Year - 18 Months
Over 18 Months

DOCUMENTS INCLUDED
The following documents must accompany this form to consider client's request. Please check all to confirm.
Documents Included

 Police Report (If Applicable)
Demand Letter

Policy Claim # & Policy Limits
Medical Billing/Statements

Hospital/Emergency Room Reports
Witness Statements

Medical Reports
Pleadings

Expert Witness Statements
Legal Pleadings
This document authorizes the release of all legal, and medical documents, police reports and insurance records and correspondences, regarding this incident to Nationwide Litigation Funding for the sole purpose of evaluating my application for an investment.

DATE: 7/29/2010





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