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)
Drop files here or
*
- I Agree
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.

Attorney Information