Settlement Advance Application

Please submit the following settlement funding information to be enrolled in our settlement advance program.

Attorney Information

Bar Number

First Name*

Last Name*

Firm Name*

Email*

Assistant First Name

Assistant Last Name

Assistant Email

Office Phone*

Fax Number*

Address

City

State

Zip

How did you find out about us?

Referrer

Referring Broker Name (if applicable)

Patient Information

First Name*

Last Name*

Gender*

Phone Number*

Email*

Date Of Birth:*

Date Of Injury*

Driver's License:*

DL State

Address

City

State

Zip

Dollar Amount Requested*

At Fault Party

First Name

Last Name

Address

City

State

Zip

Type Of Claim

Insurance Carrier

Claim Number

Upload Supporting File(s)

I hereby request and authorize Beacon Legal Funding to contact my attorney to obtain relevant case information and/or records for purposes of evaluating my settlement advance request while understanding that these parties are subject to strict confidentiality. I request and authorize my attorney to cooperate with and release to Beacon Legal Funding any and all information pertaining to my case, including candid opinions regarding this action.

Settlement Advance Application

Attorney Information

Patient Information

At Fault Party

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