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Legal Funding Group Application

Application Form

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No credit check is performed. This information is for identification purposes only.

Client's First Name:

Social Security #:

Last Name:

Female Male

Address:

Example: (XXX) XXX-XXXX

City:

Daytime Phone:

State:

Mobile Phone:

Zip:

E-mail Address:

Date of Birth:

/ /

Employer's Name:

Business Phone:

Job Title:

Business Fax:

Attorney Information

Attorney's First Name:

Last Name:

Firm Name:

Address:

City:

State:

Phone:

Zip:

Fax:

Accident Information

Date of Accident:

/ /

Motor Vehicle Accident:

Yes

Client Employed at the time:

Yes

Injury covered by Worker's Comp:

Yes

Client able to work
at the time:

Yes

Describe Accident:

Describe Injuries Sustained:

Describe Medical Treatment:

MRI:

Yes

Taken to the Emergency Room:

Yes

Surgery:

Yes

Length of Hospital Stay:

Still in Treatment:

Yes

Amount Advanced by Other Companies (if any)

Amount Requested:

Please tell us how you found our web site:

I hereby authorize my attorney of record in my lawsuit/claim to release all necessary information to:

Legal Funding Group, LLC
215 W. Bandera Road
Suite 114-408
Boerne, TX 78006
Phone (830) 249-2109
Toll Free (877) 457-7771
Fax (310) 878-0592

We represent that we will keep this information confidential unless we must respond to a lawful court order or subpoena.

Thank you for submitting your application for our review. The submittal of your application is not a guarantee of funding. By submitting your application you agree that the Legal Funding Group (LFG) automation process will capture and store your IP address (38.103.63.17) for security purposes only. LFG in no way offers your information for sale or exchange. Should you have any questions, please feel free to call us toll free at: (877) 457-7771. Monday through Friday 9:00 AM - 5:00 PM CST. Our office is closed on all governmental holidays.