* Amount Requested $

Title

Select MR. MRS. MS

* First Name

* Last Name:

* Address

Apt/Suite

* City

* State

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* Zip Code

Date of Birth

Social Security Number

Note: We will use your social security number to check for any liens on your case by other parties

* Email

* Home Phone Number

Work Phone Number

Cell Phone Number

LAWYER CONTACT INFORMATION

* Attorney's Name

* Name of Legal Assistant

* Attorney Address

Attorney Suite

* Attorney City

* Attorney State

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* Attorney Zip

* Attorney Email

* Attorney Phone Number

Attorney Fax Number

Case Information
Please tell us about your lawsuit and facts about the accident.

Date of Incident

Ineligible States:
Alabama, Alaska, District of Columbia, Hawaii, Louisiana, Maine, Nevada, Ohio,South Dakota

Location of Incident

* Location of Incident: City

* Location of Incident: State

Select AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY CAN PR UK

Types of cases we fund
(We do not fund cases for Attorney Malpractice or Worker's Compensation Claims)

Wrongful Death
Airplane Accidents
Appeals
Assault and Battery
Automobile Accidents
Bicycle Accidents
Boating Accidents
Burn Injury
Chemical or Toxic Injuries
Construction Accidents
Dog Bites
Longshoreman's Claims
Maritime/Seaman's Claims (Jones Act)
Medical Malpractice
Motorcycle Accidents
Nursing Home Neglect
Pedestrian Accidents
Premises Liability
Product Liability
Railroad Claims (FELA)
Slip and Falls

Describe the accident

We do not fund cases for soft tissue or "whiplash" injuries.

Briefly describe your injuries

* Current Medical Bills $

Describe any Recommended Treatment or Surgeries

Have you had surgery?

Yes
No

If yes, date?

Describe any Prior Injuries or Pre-existing Conditions

Have you missed work?

Yes
No

How much time?

Current Lost Wages $

PRIOR LIEN INFORMATION

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

Yes
No

If yes, please list ALL assignments against this case other than medical liens and attorney fees

Name of Company1

Amount of lien$ 1

Date of Lien1

Name of Company2

Amount of lien$ 2

Date of Lien

Name of Company3

Amount of lien$ 3

Date of Lien3

Please answer the following questions. Have you ever...

Changed attorneys in this case?

Yes
No

Declared bankruptcy?

Yes
No

Is there anything else you would like us to know about your case?

AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize and direct you to release to a representative of Fast Funds, Inc. any portion of my file they require that is related to the incident of

* Enter date of incident here:

I acknowledge that I understand the benefits and detriments of non-recourse funding. I further acknowledge I understand the effects of disclosing the contents of my file, including waiver of the attorney-client and work product privileges. Sincerely,

* Authorization Full Name

* Authorization Date

* By clicking here you incidate that your have read and agree to the Authorization for Release of Information. You must check this box to have your application processed. This gives Fast Funds permission to contact your attorney and review your case file. All information is held strictly confidential.

Submission of this application does not guarantee that Fast Funds, Inc. will offer to fund a portion of your case or that you accept any potential funding offer potentially made by us.

* Please enter the security code shown below: