DOWNLOAD A PRINTER-FRIENDLY APPLICATION (232 KB PDF)

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Plaintiff's Legal Name
Street Address
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
Zip Code
Telephone (day)	() -
Telephone (evening)	() -
Email Address
Employer Name
Street Address
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
Zip Code
Telephone	() -
Occupation:
Date of Birth
Social Security Number
Marital Status?	Mar.   Sin.   Div.   Wid.
Number of Children
Filed Bankruptcy Currently (past year)?	Yes   No
Filed Bankruptcy Previously (over 1 year ago)?	Yes   No
Have You Ever Been Convicted of a Felony?	Yes   No
If Yes to Above, Please Explain
Law Firm
Attorney's Name
Attorney's Street Address
Attorney's City
Attorney's 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
Attorney's Zip Code
Attorney's Telephone	() -
Attorney's Fax	() -
Attorney's Email Address
Fee Arrangement?	Contingency   Hourly
Event Description
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
Date of Accident
Briefly Describe What Happened
Describe Your Injuries
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?	$
Property Damage
Lost Wages?	Yes   No
Wages Lost Per Day	$
Number of Days Wages Lost
Insurance Carrier
Policy Limits
Settlement Offer Made?	Yes   No
Amount	$
Suit Filed?	Yes   No
Date of Suit Filing
Attempted Mediation?	Yes   No
Date of Mediation
Demand Letter Sent?	Yes   No
Amount of Demand Letter	$
Judgement?	Yes   No
Amount of Judgement	$
Amount of Advance Requested	$

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Equity Litigation Funding
P.O. Box 21806
Lexington, Kentucky 40522-1806