Eagle Legal Funding - Pre-settlement funding of lawsuits

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Date:
The Answers you give on this form are for Eagle Legal Funding and its affiliates use only. The information obtained will be used by Eagle Legal Funding only in the analysis and evaluation of your funding request. Please fill out what you can, some of the questions may not apply to your case, so it is ok to answer only the questions in which you are familiar.
Contact Information
First Name:
Last Name:
Middle Initial:
Maiden Name:
Home Phone:
Address:
City:
State:
Country:
Zip Code:
Cellular Phone:
Work Phone:
Email Address:
Place of Birth:
Date of Birth:
Marital Status:
Have you filed for bankruptcy since the date of a lawsuit?

CASE INFORMATION:
The name of the defendant(s) against whom Your claims are being asserted (who are you Suing?):
Has a lawsuit been filed?
The court and state in which any lawsuit has been filed:
The date (approximately) on which the lawsuit was filed:
What is the basis of your lawsuit? Please give a brief statement of what your case is about and a description of the damages you have suffered:
Has your deposition been taken?
Has your attorney made a settlement demand?
Has the defendant filed a motion for summary judgement?
If yes, has the motion been ruled on?
If yes, what claims survived? (Please Explain)
If no, when do you anticipate a ruling?
Does the defendant have insurance that will cover the claim?
If so, what is the name of the insurance company?
What are the policy limits?
Do you have a trial date set?
If yes, when is the trial date?
Attorney Information:
Your Attorney's Name:
Law Firm Name:
Street Name:
Suite:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email Address:
Prior to hiring your present attorney, had you hired another attorney to represent you regarding this specific incident?
If so, please give the name, address and telephone number and when the attorney started and stopped handling your legal matter:
LIENS AND ASSIGNMENTS ON YOUR CASE
Please indicate the liens and assignments (if any) on your case. If you do not have a lien, write "none" in the application box.
Attorney Liens: (state % of recovery or amount): $
Other liens or Assignments: $
FUNDING INFORMATION:
What is the amount you are requesting from Eagle Legal Funding?
Have you applied for any loans or advances against.
If so, please give the name of the funding companies and Date (s) of the applications(s) against:
Companies and date(s) of application(s):
Have you already received any loans or advances against this case?
If so, please give the amount, name of the company and the date of the loan/advance:
How did you hear about Eagle Legal Funding:
Which search engine did you use to find us?
What keywords did you type into the search engine to find us?

DOCUMENT AND INFORMATION RELEASE:
In order to evaluate your request for funding; Eagle Legal Funding will need to obtain certain information and documentation from your attorney. By providing your signature below, you are requesting and authorizing your attorney to cooperate and release to Eagle Legal Funding or its affiliates any and all information and/or documents relating to your claim or lawsuit, including all information in the file that is not protected by the attorney-client and/or work product priviledge. You are further requestion and instructing your attorney to share his/her candid opinions regarding your claim or lawsuit with Eagle Legal Funding, its representatives and affiliates.
Providing your name here gives us the right to consider this a signature:
>>>> Please submit this form

IMPORTANT: YOU MUST SIGN AND SUBMIT A RECORDS RELEASE FORM PRIOR TO ACCEPTANCE!

ACCESS THE RECORDS RELEASE FORM HERE:

RECORDS RELEASE
We require certain information regarding your claim or lawsuit for our underwriting process. Please sign this Records Release, authorizing your attorney to share information about your claim or lawsuit with us.

Dear Attorney ________________________________________________

I/We, the undersigned, hereby request and authorize your firm to cooperate and release to Eagle Legal Funding. ("Eagle Legal Funding"), or its affiliates, * any and all information and documents pertaining to my/our current claim or lawsuit, including pleadings, discovery, investigation, contracts, medical records/report, deposition, and all other information in the file not protected by the attorney-client privilege, the work product doctrine, or other applicable evidentiary privileges or protections. A copy and/or facsimile of this release bearing the signature of the undersigned shall be deemed to be the equivalent of the original.

Thank You.

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Print Name	Date


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Signature	Social Security