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Lawsuit Type*

State the accident/injury occurred?*

Has a lawsuit been filed?*

Has a demand been filed?*

Has the insurance company offered a settlement?*

What was the amount?

Have you received previous funding?*

Date loan taken

MM

DD

YYYY

I hereby authorize my attorney to provide Doubleday Funding, LLC with all information, oral or written pertaining to my action. I understand that it is imperative that all information shared is honest and forthcoming in order to properly evaluate my requested funding.*

Yes
No

By submitting this form, I agree that all the information listed is accurate and correct. In order to obtain information about your case, we need your authorization for your attorney to release your case file and other information regarding your case. We cannot proceed without such authorization. In doing so I am agreeing to waive my attorney client privilege and hereby acknowledge and understand the risks and benefits of non-recourse funding.*

You have read the terms and conditions and accept them.

Yes

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