Application Form

Application For Pre-Settlement Legal Funding

This form is for new Impact Legal Funding clients to apply for a pre-settlement funding advance. If you are already an Impact Legal Funding client and would like to request additional funding, please call 1-833-CASH-YES

First Name *

Last Name *

Email *

Phone Number *

Date of Birth *

Address Line 1 *

Addrress Line 2

City *

State *

Date of Incident(s), Accident, or Injury *

Zip Code *

Describe Incident(s) ? Accident / Cause of Injury: *

Describe the nature of your Injuries: *

Amount of Funding Requested: *

How did you hear about us? If referred by a friend, please list their name: *

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 without it.

Enter your Attorney's name *

Enter your attorney's phone number *

I request and authorize my attorney to provide Impact Legal Funding with whatever information (whether oral or in writing) needed to evaluate my pre-settlement 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 Impact Legal Funding any and all information and documents pertaining to my case. Please share your candid opinion regarding this action with Impact Legal Funding, so that Impact Legal Funding 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.

Your First Name *

Your Last Name *

Date *

Records Release Authorization By clicking below, 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. We charge a $250 application fee, only for funding requests which we approve and only for cases in which we provide funding. The application fee is not due until you receive your settlement or award at the end of your case. If you lose your case, you owe us nothing.

By submitting this form I agree that all the information listed is accurate to the best of my knowledge.*

I agree *