Personal Injury/ Workers Compensation Application

Transcription

1 Personal Injury/ Workers Compensation Application Ridgedale Drive, Suite 230 Minnetonka, MN F: Toll Free: CLIENT CONTACT INFORMATION Name: Home Address: City: State: Zip: Home Phone: Home Fax: Cell Phone: Employer: Work Address: City: State: Zip: Work Phone: Work Fax: PERSONAL CLIENT DATA Date of Birth: Spouse Name: Marital Status: S M D W Age of Child(ren): Child(ren): Yes No Monthly Child Support: $ Child Support: Yes No When Filed: Current Bankruptcy: Yes No When Filed: Previous Bankruptcy: Yes No Explain: Criminal Record: Yes No Employer SSN: Occupation Monthly Salary $ ATTORNEY INFORMATION Name: Law Firm: Address: Phone: City: Fax: State: Zip: Fees: Contingent % Hourly: $ Recovery to be deposited in Trust Account: Yes No 1

2 TYPE OF CASE Auto Accident FELA/Jones Act Medical Malpractice Premises Liability Product Liability Workers Compensation Other CASE DETAILS Briefly describe the facts of the case. ACCIDENT INFORMATION Date of Accident/Injury: Time of Accident/Injury: AM/PM Citations/Tickets: Yes No DWI/DUI: Yes No You: Yes No You: Yes No Other Party: Yes No Other Party: Yes No Name of Police Department: INJURY INFORMATION Briefly describe the nature and extent of injuries. MEDICAL INFORMATION Name of Physician(s): Chiropractic Treatment: Yes No Are You Currently Treating? Yes No If Yes, (Chiro) are You Still Treating? Yes No Pre-Existing Conditions: Yes No If Yes, Explain: Previous Injuries: Yes No If Yes, Explain: Prior Settlements: Yes No If Yes, Explain: Future Medical Treatment Expected: Yes No If Yes, Explain: Was an MRI done? Yes No If Yes, Result: Who is paying your medical bills now? 2

3 INSURANCE INFORMATION Your Insurer: Policy Limit: Negligent Party(s) Insurer: Policy Limit: WORKERS COMPENSATION INFORMATION (if applicable) Employer: Insurance Co.: Weekly Benefit: No. of Weeks: Amount Paid to Date: $ No. of Weeks: Previous WC Claims: Yes No Explain: Client Returned to Work: Yes No If No, Expected Date: Are Benefits Being Paid? Yes No If Yes, Amount: $ LIENS AND OTHER ENCUMBRANCES Child Support Liens: Yes No $ Alimony Liens: Yes No $ Tax Liens: Yes No $ Prior Loans/Advances: Yes No $ Other (i.e. Medical) $ SETTLEMENT INFORMATION Settlement Offer Made: $ Estimated Settlement Date: Date of Offer: FUNDING REQUEST Amount: $ USE OF FUNDS Personal Debts: Yes No $ Case Costs: Yes No $ Attorney s Fees: Yes No $ Other: Yes No $ OTHER COMMENTS Please provide any additional information regarding liability, damages and/or collectibility. PREPARED BY Print Name: Date: Signature: CONFIDENTIALITY NOTICE: All information provided herein is for underwriting purposes only. All information shall be held in strict confidence and shall not be disclosed to any third party unless so instructed to do so by client, counsel or court order. 3

4 Records & Information Release Ridgedale Drive, Suite 230 Minnetonka, MN F: Toll Free: Dear Attorney : : I/We, the undersigned, hereby request and authorize your firm to cooperate and release to Prospect BridgeFunds, Funding LLC any Partners and all information LLC any and and all documents information pertaining and documents to my/our pertaining current to claim my/our or lawsuit, current including claim or lawsuit, including pleadings, pleadings, discovery, discovery, investigation, investigation, contacts, medical contacts, records/reports, medical records/reports, depositions depositions and all other and information all other information not protected not by protected the attorney-client by the attorney-client privilege, the privilege, work product the work doctrine product or other doctrine applicable or other evidentiary applicable evidentiary privileged or privileged protections. or protections. I/We request and instruct you to share your candid opinion(s) regarding my/our claim or lawsuit with Prospect BridgeFunds, Funding LLC, Partners its representatives LLC, its representatives and agents. and agents. A copy of this authorization bearing the signature of the undersigned may be deemed to be the equivalent of the original. Thank you in advance of your cooperation. Print Name: Date: Signature: SSN: 4

5 Client ID: Client Information Release Ridgedale Drive, Suite Minnetonka, MN MN F: Toll Free: To Prospect BridgeFunds, Funding LLC: Partners LLC: Prospect BridgeFunds Funding and Partners its representatives LLC and its are representatives hereby authorized are hereby to gather authorized any information to gather any about information me/us about required me/us to complete required to your complete due diligence your due investigation diligence investigation regarding a regarding requested a financial requested transaction fanancial by transaction me/us. Such by information me /us. Such may information include, but may is include not limited but is to, not financial limited and to, financial credit information, and credit information, consumer credit reports and and any any information concerning liens liens and and judgments against against me me/us. A copy of this authorization bearing the signature of the undersigned may be deemed to be the equivalent of the original. Thank you in advance of your cooperation. Print Name: Signature: Telephone No: Date: SSN: Date of Birth: Address: City: State: Zip: 5