Certified Legal Funding, Inc. - Online Application Form

Certified Legal Funding, Inc.

Phone:
(800) 922-7439

Fax:
(800) 941-8411

email us

Application
Your Information			Attorney Information
First name	A value is required.Invalid format.
Middle Initials
Last Name	A value is required.Invalid format.		Name of Attorney	A value is required.Invalid forma
Address 1	A value is required.Invalid format.		Attorney Email Address
Address 2			Case Manager
City	A value is required.Invalid format.		Law Firm
State	A value is required.Invalid format.		Address 1
Zip	A value is required.Invalid format.		Address 2
Social Security	Invalid format.		City
Date of Birth	Invalid format.A value is required.		State
Email Address	Invalid format.		Zip Code
Phone Number	A value is required.Invalid format.		Phone Number	A value is required.Invalid format.
Cell Phone Number	Invalid format.		Fax Number

Case Information
Accident date		A value is required.Invalid format.
Who was driving
Whose fault was the accident?		A value is required.Invalid format.
Brief description of the case
Brief description of any Injuries and Sugeries
Additional comments
How much are you requesting? $		A value is required.Invalid format.
Your insurance company
Name of the other party's insurance company


By submitting this application, I hereby grant Certified Legal Funding, Inc. permission to contact my attorney to obtain any and all other information (including medical records) relating to my case/claim, and I hereby instruct my attorney to cooperate with Certified Legal Funding, Inc. in this regard.