Consultant Cash Advance Request

settlement funding and interim settlement

Application

	Click on the icon to download Application Word format
	Click on the icon to download Application PDF format
	Click on the icon to find the states we provide workers' compensation loans

You are always welcome to electronically send us your clients application
via the electronic application below:

Client Information

First Name

Last Name

Address

City

State

Zip Code

Home Phone Number
- -

Other Contact Phone Number
- -

Work Phone Number
- -

Attorney Information

Attorney's Name

First Name

Last Name

Attorney's Firm

Address

City

State

Zip Code

Attorney's Phone Number
- -

Attorney's Fax Number
- -

Information Related to Injury

Date of Accident or Injury / /

Describe Accident

Describe Injuries

Other Information

Amount of funds being requested

Consultant Information

First Name

Last Name

Consultant's Phone Number
- -

YES, I do certify that the information supplied by me to be true and correct. By electronically signing this document, I acknowledge that I have read, understand, and agree to all the terms and conditions of this Release and Authorization Form.
No, I do not agree with the above statements.

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A Representative will be calling you shortly to review your application!

	National Lawsuit Funding LLC
	333 Naamans Road Suite 15A
	Claymont, DE 19703
	Phone:	(302) 792-1400; (888) 322-2400
	Fax:	(302) 792-1800
	E-mail: