Attorney Questionaire

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Attorney Questionaire

National Lawsuit Funding prefers discussing case details on the phone so we can truly feel out the case.
But, this day in age, a lot of attorney's request a written form.
Try to be as candid and detailed as possible.

Client Info

* Indicates required field

Client Name *

First

Last

Client Phone Number *

Attorney Info

Attorney Name *

First

Last

Attorney Phone Number *

Attorney Email *

Case Details

Type of Case *

Auto S&F W/C Med Mal Other

Date of Accident *

At Fault Liability Carrier *

Claim # *

Liability Carrier's Adjuster's Name & Phone Number *

Policy Limit's (if known) *

Liability Accepted? *

Yes No Undetermined

Soft Tissue Injuries *

Yes No

List surgery/injections/etc if more than soft tissue *

Total of Meds (if known)? (an estimate is ok) *

Prior Fundings? *

Yes No Not sure

If there are prior fundings, how much and from whom? *

BRIEFLY Describe Accident *

What Else Would you Like us to know about the case/client? *

Submit

Address

505 York Rd
Suite 106
Jenkintown, PA 19046

Telephone

888-322-2400 (p)
215-798-0644 (f)

Email

info@nationallawsuitfunding.com

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Home
Process
Contact
Questions
Apply
ReApply Form
888-322-2400