Apply Now Personal InformationName: First Last Address: State / Province / RegionE-mail:Phone: Area Code - Phone Number Case InformationDate of Event: Case Type: How did the accident happen?Attorney InformationAttorney Name: First Last Name of Law Firm: Attorney's Phone No: Area Code - Phone Number Attorney's Fax No: Request InformationAmount: * Authorization to Contact AttorneyI hereby request and authorize Capital 7 Claim Funding and/or funding sources in its network to contact my attorney to obtain relevant non-privileged case information for purposes of completing a funding request. I understand that these parties are subject to a strict confidentiality. Additionally, I authorize my attorney to share his/her candid opinion regarding my case.Do you authorize Capital 7 Claim Funding to contact your attorney and request the release of your records?:Yes or No: Sign Full Name:
