Pre-Settlement Healthcare Funding Group Application

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No credit check is performed. This information is for identification purposes only.

Client's First Name: Social Security #:
Last Name: Female  Male
Address: Example: (XXX) XXX-XXXX
City: Daytime Phone:
State: Mobile Phone:
Zip: E-mail Address:
Date of Birth: //
Employer's Name: Business Phone:
Job Title: Business Fax:

Attorney Information
Attorney's First Name:
Last Name:
Firm Name:
Address:
City:
State: Phone:
Zip: 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
at the time:
Yes No
Describe Accident:
Describe Injuries Sustained:
Describe Medical Treatment:
MRI:
Yes No
Taken to the Emergency Room:
Yes No
Surgery:
Yes No
Length of Hospital Stay:
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, which occurred
on // , to release all necessary and requested information to:

Pre-Settlement Healthcare Funding Group, LLC
5550 Painted Mirage Road Suite 320
Las Vegas, NV 89149
Phone (702) 944-4188
Toll-free (888) 833-5715
Fax (702) 921-6087

We represent that we will keep this information confidential unless we must respond to a lawful court order or subpoena.
Signed: Client
Print name: Client
Date: //
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 (66.249.71.39) 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 (702) 944-4188 or toll-free (888) 833-5715 Monday through Friday 9:00 AM - 5:00 PM PST. Our office is closed on all governmental holidays.