Application for Surgical Funding - Plaintiffs

Application for Surgical Funding – Plaintiffs

Name of Claimant*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security #
Address*
Street Address Address Line 2 City ZIP Code
State*
Contact Number*
Email*
Prior Funding?*
With Whom / Amount $
Date of Accident*
Date Format: MM slash DD slash YYYY
Description of Accident*
Injury/Type of Surgery*
Insurance Company or Self-Insured*
Policy Limits*
Name of Plaintiff's/Firm Counsel*
Email Address or Best Way to Contact Firm*
In order to obtain information about your case, we need your authorization to release your case records and information to us. We cannot proceed without it.
Enter your ATTORNEY'S NAME here*
I request and authorize my attorney to provide LawCash with whatever information (whether oral or in writing) needed to evaluate my funding request. I specifically waive any privilege that I may have regarding such information. 

I hereby request and authorize your firm to cooperate with and release to LawCash any and all information and documents pertaining to my case. Please share your candid opinion regarding this action with LawCash, so that LawCash can evaluate my funding request.

I acknowledge that I understand the benefits and risks of non-recourse funding. I further acknowledge that 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 your cooperation.
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY