ONLINE PLAINTIFF APPLICATION

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:

$ *

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

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 *

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.