Empire Settlement Funding does not fund Workers Compensation cases in Alaska, Arkansas, California, District of Columbia, Hawaii, Kansas, Kentucky, Maryland, Michigan, Minnesota, Nevada, New Jersey, New York, North Carolina, Oregon, Pennsylvania, Texas, Utah, Virginia, Washington, or Wisconsin. 

Your information is safe, secure and confidential with Geotrust protection.

1. CASE INFORMATION             

Case Type:

Auto Premises Products Construction

Medical Malpractice Worker's Compensation Wrongful Death Other - including Commercial

State of Court:

State AL AR AK AZ CA CO CT DC DE FL GA DE HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Case Details:

2. CONTACT INFORMATION: Please provide the following information so we may contact you.

	Last name:
	First name:
	Date of Birth:	- 1 2 3 4 5 6 7 8 9 10 11 12 / - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / - 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927
	Phone Number:	- -
	Alternate Phone Number:	- -

	E-mail address:
	Home address:
	City:
	State:	State AL AR AK AZ CA CO CT DC DE FL GA DE HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
	Zip code:

3. AMOUNT OF MONEY REQUESTED: Please indicate the amount of money you need.

$

4. ATTORNEY INFORMATION

	Attorney Name:
	Law Firm Name:
	Phone number:	- -
	Fax number:	- -

	Address:
	City:
	State:	State AL AR AK AZ CA CO CT DC DE FL GA DE HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
	Zip Code:

5. LIENS AND ASSIGNMENTS ON YOUR CASE: Please indicate the liens and assignments (if any) on your case. If you do not have a particular type of lien, write "none" in the applicable box.

	Attorney's fees (ie. 33%):
	Other liens or assignments:

	Currently in bankruptcy:	yes no
	Changed attorneys in this case:	yes no
	Obtained a prior advance on this case:	yes no

If you answered yes to any of the above questions, please explain:

6. CERTIFICATION The information provided in this application is true, accurate, and complete, to the best of my knowledge and belief.

	Name:
	Do you authorize attorney to release documents to us to help fund your case?	yes no

Date:

7. User Authentication

Enter the Security Code Before Submitting:

***Submission of this application is not a guarantee that Empire Settlement Funding will offer to purchase a portion of applicant's potential settlement or judgment proceeds. Submission of this application is not a guarantee that applicant will accept any potential purchase offer made by Empire Settlement Funding, LLC