Personal Information

Name:
Address:
E-mail:
Phone:
-

Case Information

Date of Event:
Case Type:
How did the accident happen?

Attorney Information

Attorney Name:
Name of Law Firm:
Attorney's Phone No:
-
Attorney's Fax No:

Request Information

Amount: *

Authorization to Contact Attorney

I hereby request and authorize Capital 7 Claim FundingĀ 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: