Lawsuit Funding Request Form

Please answer all questions and then submit your Pre-Settlement Lawsuit Funding Application for consideration. We will contact you with an indication of our interest in pursuing your funding request. IMPORTANT: WE DO NOT ADVANCE ON WORKMAN'S COMP CLAIMS NOR ANY CLAIMS IN THE STATE OF OHIO.

ALL INFORMATION IS CONFIDENTIAL

PLAINTIFF INFORMATION (Injured Party)

Plaintiff's Name:

Date of Birth:

MM/DD/YYYY

Occupation:

Telephone #1:

Telephone #2:

Address:

City:

State:

Zip:

Email:

10.

Best Time To Call:

ATTORNEY INFORMATION

11.

Attorney's Name:

12.

Name of Law Firm:

13.

Secretary/Paralegal's Name:

14.

Address:

15.

City:

16.

State:

Zip:

17.

Telephone:

18.

Fax:

THE LAWSUIT

19.

Date of Accident or Incident:

20.

Defendant (Liable Party):

21.

Case Status:

22.

Type of Case:

23.

Amount of Damages Seeking:

24.

Advance Needed ($1,000 min.):

25.

Have You Received a Previous Advance on This Case?:

Yes No

26.

If Yes, How Much?:

27.

If Yes, From What Company?:

28.

Briefly Describe the Incident.

29.

Briefly Describe your Injuries.

Referred By: (for Affiliate or Broker use)

Affiliate/Broker:

E-Mail:

Phone:

FAX:

I hereby authorize the designated representatives or any of their successors, assigns, designees, agents or administrators to disclose, make available and furnish to First American Finance Corp., ISAOA ("FAF") any and all information pertaining to the settlement of my case as set forth. I specifically direct that the attorney representing me in my case or any of their successors, assigns, designees, agents or administrators cooperate with FAF regarding disclosure of information related to the settlement of my case. Please provide copies via fax or otherwise of any and all documents requested by FAF. I also request that my attorney share his candid opinion of my case with FAF.

I instruct and authorize my attorney to forward my case information to FAF for evaluation upon request Yes No

By submitting this form, I/We certify that all of the information provided above is true and correct. I/we understand that any intentional misrepresentation on my/our part will result in the immediate cancellation of any assignment, loan or purchase made in connection with this application.