Please fill out as much of the form below as you can. Except where indicated, leave blank any questions you cannot answer. We can get additional information from you and your attorney later. If you're having trouble with this application, call toll free 1-866-798-2941 and we'll take your application over the phone.

* Amount Requested $

* Name

* City

* State

* Email

* Best Number to Reach You

LAWYER CONTACT INFORMATION

* Attorney's Name

* Attorney Phone Number

Case Information

Please Tell us About Your Lawsuit and Facts About the Accident.

Describe Your Injuries

Ineligible States:
Alaska, Colorado, District of Columbia, Hawaii, Illinois, Maine, Missouri, Nevada, North Carolina

Briefly describe your injuries

Have you had surgery?

Yes
No

Describe any Prior Injuries or Pre-existing Conditions

PRIOR LIEN INFORMATION

Have you ever obtained cash or funding from another company for this case?

Yes
No

Name of Company

Amount of lien$

Submission of this application does not guarantee that Fast Funds, Inc. will offer any funding.


      

While walking, I was severely hurt by being struck by a drunk driver. I suffered a broken leg, broken ribs, and a head injury. I was unable to work and unable to support myself. Because of this, bills began to pile up and I had difficulty even paying for my on-going medical treatment. I was getting very worried until a friend recommended that I call Fast Funds. Within just a day, you gave me my approval and I received the money almost immediately. It is so wonderful to have the financial weight lifted while I recuperate and wait for my accident settlement.
Thank you so much,
J.R.