Nationwide Litigation Funding

* Attorney's Name:
Co-Counsel:
* Address:
* City:
* State/Zip:	Zip:
* Attorney's E-mail:
Attorney's Phone:
Attorney's Fax:
Client's Name:
* Nature of Incident:
Date of Incident:
* Proof of Liability:	Yes No
Medical Specials:
Future Medical Specials:
Amount of Liens:
Lawsuit Filed?:	Yes No
(If Yes) When?:
(If Yes) Case No.:
Where?: (County)
Lawsuit Answered?:	Yes No
(If Yes) When?:
* Estimated Case Value:	Low: High:
Insurance Carrier:
* Claim:
Policy Limit:
Are any of the parties or their insurance carriers in Bankruptcy, Receivership or Liquidation?
Yes No
If Yes, Please Identify Such:

I promise that the information provided regarding said lawsuit is truthful and complete to the best of my knowledge. 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:
State Bar No:



The transmission or receipt of any materials from or through this website, including text, graphics and/or e-mail, is not intended to create, nor does receipt of these materials establish or constitute, a contractual relationship or attorney-client relationship between Nationwide Litigation Funding and you or anyone else.

* Name:
* Address:
* City:
* State/Zip:	Zip:
How long at this address?:
* Email:
* Home Phone:
Home Fax:
Social Security #:
Drivers License#:
* Date of Incident:
* Nature of Incident:

I promise that the information I will provide respecting my lawsuit will be complete and truthful to the best of my knowledge. 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 funding.
Date:



The transmission or receipt of any materials from or through this website, including text, graphics and/or e-mail, is not intended to create, nor does receipt of these materials establish or constitute, a contractual relationship or attorney-client relationship between Nationwide Litigation Funding and you or anyone else.