Lawsuit loans, Lawsuit Settlement Loan: SMP Advance Funding Case Loan Application

Application

This information is for identification and information purposes only the submittal of your application is not a guarantee of funding. SMP in no way offers your information for sale or exchange.

Applicant's Personal Information

Name:*		Date of Application:
Address:		Home Phone:*
City:		Cell Phone:
State:		Work Phone:
Zip Code:		Email:*
Date of Birth:		Referral Source:
Social Security No:

Employer/Defendant Information

Employer/Defendant:
Employer/Defendant Address:
Employer/Defendant City:
Employer/Defendant State:		Employer/Defendant Zip Code:

Attorney Information

Lawyer's Name:		Phone:
Firm Name:		Fax:
Firm Address:		City:
State:		Zip Code :

Accident/Incident Information

Date of Accident/Incident:
Case No.:
Type of Case:
Describe the Accident/Incident:
Second Accident/Incident (if applicable):
Case No:
Type of Case:
Describe the Accident/Incident (if applicable):

Workers Compensation (if applicable)

Insurance Carrier (Work Comp):
Applicant's Average Weekly Wage:
Applicant's TTD Wage (if applicable):
Total Period of Lost Time:
Did Insurance Carrier Pay Lost Time Benefits (TTD)?
Is Applicant Presently Working?
Is Applicant Still Employed with Employer?

Medical Treatment (if applicable)

Did the Applicant Have an MRI?
Is the Applicant Still Treating?
Did the Applicant Have Surgery?
Describe the Medical Treatment:

Injury Information

Describe the Injuries Sustained:

Additional Questions

Is the Applicant Receiving Social Security or Medicare Benefits?		If So, When?
Is the Applicant Receiving Public Aid Benefits?
Is the Applicant Paying Child Support?
Has the Applicant Filed for Bankruptcy (chapt 7 or chapt 13)?		If So, When
Has the Applicant Ever Been convicted of a Crime?		If so, What?
Has the Applicant Ever Been Incarcerated?

Money Information

How Much Money is the Applicant Seeking?
What Does the Applicant Need the Money For?

Other Loans

Has the Applicant Taken Out any Other Loans/Advances Against their Case?
If so, When?
If So, Where is the Loan/Advance From?
How Much Money was the Loan/Advance for?
* Required Fields