Client Funding Intake Form

Requested Amount (leave blank if unknown):

Client Name:

Client Phone Number:

Attorney Name:

Attorney Phone Number:

Paralegal Name:

Paralegal Email:

Type of Case:

Date of Accident:

At-Fault Insurance (if known):

Liability Accepted:

Extent of Injuries:

Stage of Case:

Prior Funding Amount (or “none”):

Any other Items to note?

Supporting Documentation (optional)

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Police Report

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Medical Report

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Complaint

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Any other documents you want us to review

thank you

Thank you for your interest in an advance from National Lawsuit Funding. A representative should be reaching out soon to help you. Please let your attorney know that National Lawsuit Funding will be reaching out to them and, if possible,
have them call us at 215-885-3700 to help make your funding process go faster.

Thanks,

Matt
National Lawsuit Funding

215 885 3700

matt@nationallawsuitfunding.com

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