Application

This information is for identification purposes only. The submittal of your application is not a guarantee of lawsuit settlement funding. SMP in no way offers your information for sale or exchange.
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APPLICANT'S PERSONAL INFORMATION
*Date of Application:
*Full name:
*Home Phone:
*Address:
*Cell Phone:
*City:
Work Phone:
*State:
*Zip Code:
*Email:
*Date of Birth:
Referral Source:

EMPLOYER / DEFENDANT INFORMATION

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

ATTORNEY INFORMATION

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

ACCIDENT / INCIDENT INFORMATION

Date of Accident / Incident:
Case #:
Type of Case:
Did the applicant visit the ER on the date of accident?
If no, what was the first date of medical treatment?
Describe The Accident / Incident:
2nd Accident / Incident (if applicable):
2nd Case #:
2nd Type of Case:
Did the applicant visit the ER on the date of accident?
If no, what was the first date of medical treatment?
Describe The 2nd Accident / Incident:

FOR CAR ACCIDENTS

Was a police report completed?
Was Defendant’s vehicle insured?
Was the vehicle applicant was in insured?
Was applicant in a work vehicle at the time of accident?
Is there Uninsured/Underinsured motorist coverage available?

WORKERS COMPENSATION (IF APPLICABLE)

Insurance Carrier (Work Comp):
Applicant's Average Weekly Wage:
Did Insurance Carrier Pay Lost Time Benefits (TTD)?
Applicant's TTD Wage (if applicable):
Did Insurance Carrier Pay Medical Benefits?
Total Period of Lost Time:
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 Injures 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 (Chap 7 or Chap 13)?
If So, When?
Has Applicant Ever Been Convicted of a Crime?
If So, What Crime?
Has Applicant Ever Been Incarcerated?

MONEY INFORMATION

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

OTHER LOANS

Has the Applicant Taken Out Any Other Loans or Cash Advances Against Their Case(s)?
If So, When?
If So, Where is the Loan From?
How Much Money Was the Loan For?
Applicant certifies that the answers given in this application are true and correct to the best of his/her knowledge and that he/she is at least 18 years of age. Applicant acknowledges this application is part of SMP Advance Funding's loan approval process. False and misleading statements will be sufficient reason for SMP Advance Funding to terminate any loan agreement and require immediate payment of any loan entered into by Applicant and SMP.
*Signature:
*Date:
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