What Cases Qualify?

• Personal Injury Vehicle
• Personal Injury Premises
• Personal Injury Assault
• Slip and fall
• Malpractice
• Negligence
• Exposure
• Most personal injury's due to negligence

Funding Main Application

Pre-Settlement Healthcare Funding Group Application No credit check is performed. This information is for identification purposes only. Pre-Settlement Healthcare Funding Group Application Client's First Name Last Name Address City State Zip Code Date of Birth Employer's Name Job Title Social Security # Sex Male Female Daytime Phone Mobile Phone E-mail Address Business Phone Business Fax Attorney Information Attorney's First Name Last Name Firm Name Address City State Zip Phone Fax Accident Information Date of Accident Motor Vehicle Accident Yes No Client Employed at the time Yes No Injury covered by Worker's Comp Yes No Client able to work Yes No Describe Accident Describe Injuries Sustained Describe Medical Treatment MRI Yes No Taken to the Emergency Room Yes No Length of Hospital Stay Surgery Yes No Still in Treatment Yes No Client’s Insurance Carrier Who is Paying Medical Bills Current Medical Expenses Anticipated Medical Expenses Client Receiving Outside Compensation (e.g. public assistance, welfare) Yes No Name of Defendant Defendant’s Insurance Company Amount of Claim Amount Advanced by Other Companies (if any) Please provide details for previous claims for personal injury case, whether settled, lost won or otherwise Amount Requested Information Authorization Your client, authorizes release of certain documents pertaining to his/her case for an advance consideration from our firm. I hereby authorize my attorney of record , in my lawsuit/claim, to release all necessary and requested information to: Pre-Settlement Healthcare Funding Group, LLC We represent that we will keep this information confidential unless we must respond to a lawful court order or subpoena. Signed: Additional Information Thank you for submitting your application for our review. The submittal of your application is not a guarantee of funding. By submitting your application you agree that the Pre-Settlement Healthcare Funding Group (PSHFG) automation process will capture and store your IP address for security purposes only. PSHFG in no way offers your information for sale or exchange. Should you have any questions, please feel free to call us at Monday through Friday 9:00 AM - 5:00 PM EST. Our office is closed on all governmental holidays. = Required