Please complete below.  All information is strictly confidential.  
No credit check is required.           

* denotes required field
First Name*:
Middle Name:
Last Name*:
Address*:
Address 2:
City*:
State*:
Zip Code*:
Primary Phone*:
(include area code)
Alternate Phone:
(include area code)
Email address*:
Date of Birth*:
MM/DD/YY
Accident Information:
Type of case (check all that apply):
Auto Accident

Slip, Trip and Fall     

Premises Liability

Medical Malpractice    

Workers' Compensation

FELA (Railroad)

Jones Act (Maritime)  

Class Action

Structured Settlement

Other  (please specify):
Date of Accident: MM/DD/YY
(or estimate if necessary)
In what state did this incident occur?
Details:
Summarize accident here.
Your injuries:
Treatment
(surgey, MRIs, X-Rays,
physical therapy, etc.)
How soon AFTER this
incident did you seek
medical treatment?
Attorney Information
Attorney Name:*
Case Manager/
Paralegal/Assistant:
Firm Name:*
Address:
City:
State:
Zip Code:
Phone* (###-###-####)
Fax:
Email address:
Website
Amount of Money Requested*:
To be used for*:
(i.e., Utilities, Rent, Mortgage, etc.)
RECORDS & INFORMATION RELEASE REQUEST
TO ATTORNEY'S OFFICE LISTED ABOVE
I, the undersigned, hereby request and authorize your firm to
cooperate and release all necessary and requested information and
documents pertaining to my current claim or lawsuit to XL Funding.  
I additionally request and instruct you to share your candid
opinion(s) regarding my claim or lawsuit with XL Funding its
representatives, affiliates and agents.

I understand that all information will be treated as privileged and
confidential and will only be used in the limited capacity of
underwriting my claim in consideration for a financial advance and
will not be further used or disclosed unless so instructed by myself,
my counsel or a lawful court order.
Authorization*  
Insert your initials at right in lieu of signature
EXCEL LEGAL FUNDING
PLAINTIFF FUNDING APPLICATION