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First Name*:
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Middle Name:
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Last Name*:
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Address*:
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Address 2:
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City*:
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State*:
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Zip Code*:
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Primary Phone*:
(include area code)
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Alternate Phone:
(include area code)
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Email address*:
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Date of Birth*:
MM/DD/YY
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Accident Information:
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Type of case (check all that apply):
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Auto Accident
Slip, Trip and Fall
Premises Liability
Medical Malpractice
Workers' Compensation
FELA (Railroad)
Jones Act (Maritime)
Class Action
Structured Settlement
Other (please specify):
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Date of Accident: MM/DD/YY
(or estimate if necessary)
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In what state did this incident occur?
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Details:
Summarize accident here.
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Your injuries:
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Treatment
(surgey, MRIs, X-Rays,
physical therapy, etc.)
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How soon AFTER this
incident did you seek
medical treatment?
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Attorney Information
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Attorney Name:*
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Case Manager/
Paralegal/Assistant:
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Firm Name:*
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Address:
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City:
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State:
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Zip Code:
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Phone* (###-###-####)
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Fax:
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Email address:
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Website
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Amount of Money Requested*:
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To be used for*:
(i.e., Utilities, Rent, Mortgage, etc.)
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RECORDS & INFORMATION RELEASE REQUEST
TO ATTORNEY'S OFFICE LISTED ABOVE
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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.
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Authorization*
Insert your initials at right in lieu of signature
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