Jury Rejects $2.5 Million Claim Stemming from Train Accident

Attorney name*

Law firm name*

Date of birth

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Post-settlement funding

Amount requested*

Title of action*

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Insurance company

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Applicant name*

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Employer

Date of injury

Duration of injury

Surgery required?
NoYes

Disabled from injury?
NoYes

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Are there any outstanding judgments or IRS tax liens against the applicant?
NoYes

Has the applicant been or is the applicant currently involved in a bankruptcy or insolvency proceeding?
NoYes

Has the applicant sought or received funds from any other funding company?
NoYes

Attorney name*

Law firm name*

Address

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Phone (secondary)

Fax

Email address*

Name

Date

Please provide a list of any and all liens, as well as the amounts of the liens that currently exist against any recovery the plaintiff may recieve:

Applicant's Name

There are no liens or other interests against the plaintiff's personal injury claimThe following liens exist (please select applicable below

Internal Revenue Service lienCompensationSSI / SSDWelfareRailroad Retirement BoardNo FaultMedical providers and / or other liens