Apply for an Injury Advance

Just fill out and submit our online application and disclosure form to apply for an Injury Advance today. Our team will get back to you as quickly as possible.

* Please fill out all sections of this form. Please do not leave any portions blank.

Your Information
Full name:
Date of Birth (month-day-year):
Address:
Apt:
City:
State:
Zip Code:
E-Mail Address:
Social Security Number:
Home Phone:
Work Phone:
Cell Phone:
Your Attorney Information
Attorney's Full Name:
Name of Law Firm:
Phone Number:
Fax Number:
Address:
City:
Zip Code:
Law Firm Contact (paralegal / legal assistant):
Have you ever been injured in an incident or accident prior to this case?
If yes, provide details:
Case Information
Date of Incident(s), Accident, or Injury:
Name(s) of Defendant(s):
Describe Incident(s) / Accident / Cause of Injury:
Describe the nature of your injuries:
Describe the treatments you have received for your injuries:
If you were working at the time of the incident, accident or injury, how much time did you miss from work because of the incident, accident, or injury?
Are you still able to work?
Is the attorney or law firm handling more than one accident case for you?
If yes, please provide a description of the additional case(s):
Did you receive an advance from another funding company on this case or any other case?
If yes please list Amount, Name of Funding Company, When Funded:
Are there any outstanding liens against you and/or the case? (medical, hospital, workman's comp, disability, IRS, etc.):
Have you now or ever filed for bankrutpcy?
If yes, when and where:
Was the bankruptcy discharged? If so, when?
Funding Information
Amount of funding requested:
I need these funds for:
Referral
How did you hear about us?
By submitting this form, I agree that all the information listed is accurate and correct. In order to obtain information about your case, we need your authorization to release your case records and information to us. We cannot proceed with out it.
Enter your ATTORNEY'S NAME here:
I request and authorize my attorney to provide Injury Advance Corp. with whatever information (whether oral or in writing) needed to evaluate my funding request. I specifically waive any privilege that I may have regarding such information. I hereby request and authorize your firm to cooperate with and release to Injury Advance Corp. any and all information and documents pertaining to my case. Please share your candid opinion regarding this action with Injury Advance Corp., so that Injury Advance Corp. can evaluate my funding request. I acknowledge that I understand the benefits and risks of non-recourse funding. I further acknowledge that 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 your cooperation.
Name:
Date:
By clicking here, you indicate that you have read and agree to the Records Release Authorization. You must check this box for your application to be processed. This authorization gives us permission to contact your attorney and discuss your case with your attorney. By submitting this form I agree that all the information listed is accurate to the best of my knowledge.

For further information or to
apply for an Injury Advance please call
1-888-565-4488