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LAWSUIT FUNDING NETWORK Attorney Case Evaluation Form

Your client has applied for lawsuit funding and as part of the underwriting process it is necessary that you fill out the following information outlined below to assist in the underwriting evaluation.

Thank you for your cooperation, and we look forward to assisting your client in this matter

Lawsuit Funding Network
Phone 1-866-270-1466

info@lawsuitfundingnetwork.com

The Answers you give on this form are for LSFN and its affiliates use only. The information obtained will be used by LSFN 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.
   
Attorney Questionnaire:
Client First Name:
Last Name:
   
Attorney Information:
First Name:
Last Name:
Attorney's Firm:
Address:
City:
State:
Zip Code:
Attorney's Phone Number:
   
Case Information:
Case Detail :
Date of Incident :
Suit filed? :
Yes No
Date the lawsuit was filed :
Where was the lawsuit filed? :
Case Number :
County of Court :
Demand Amount :
Offer Amount :
Case Value :
Settlement Prospects :
Good Fair Poor
Trial Date :
Liability Strengths :
Liability Weaknesses :
   
If client was injured please complete the following:
Date of Accident or Injury:
Describe Accident:
Describe Damages or Injuries:
Injuries :
Prior Injuries :
Insurance Company :
Claim # :
Policy Limits :
Please list attorney contingency fee amount:
Medical Liens:
Any Additional Liens? :
Additional Comments:
   
   
   
Image Verification:
Please enter the text from the image:
   
   
>>>> Please submit this form
 



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