Pre-Settlement Funding

Pre-Settlement Funding Application

Please complete all fields below. Your information is protected with SSL encryption and kept strictly confidential. A funding specialist will review your application and contact you within 24 hours.

Pre-Settlement Advance Application

Before Applying, speak with your Attorney and confirm he/she supports you obtaining a non-recourse, Pre-Settlement Advance. Confirm your Attorney will provide documentation and information to the underwriter so that an informed funding decision can be made. You MUST have your Attorney's support.

First Capital Financial Group LLC , are not Attorney's and do not provide Legal Advice. If you need Legal Advice, consult your Attorney.

Personal Information

Please provide your personal contact information below.

First Name

Last Name

Date of Birth

Social Security Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone Number

Best Time to Call

Case Information

Please provide details about your case below.

Type of Case

Date of Accident/Incident

Location of Accident/Incident

Description of Accident/Incident

How Much Time Did You Lose From Work As A Result of Your

Case Status

Expected Settlement Amount

Expected Settlement Date

Have You Received Any Prior Funding?

If Yes — Name of Funding Company

If Yes — How Much?

Are There Any Other Liens Against This Case?

Important Information

Please answer all questions below honestly and completely.

Have You Ever Been Injured in an Accident Before This Case?

If Yes — Please Explain

How Many Accident Lawsuits Do You Have Pending at This Time?

Have You Ever Filed Bankruptcy?

If Yes — When?

If Yes — Date Discharged?

Are You Responsible for Child Support?

Do You Owe Any Back Child Support?

If Yes — Amount Owed

Advance Amount Requested

How Did You Find Us?

Attorney Information

Please provide your attorney's contact information below.

Attorney Name

Law Firm Name

Attorney Phone

Attorney Email

Attorney Website

Attorney Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Paralegal Name

Paralegal Email

Certification & Submit

Please review your application carefully before submitting.

I have applied for a Non-Recourse, Pre-Settlement Advance (Not a Loan) from First Capital Financial Group, LLC, its funding sources, agents and/or assigns. First Capital Financial Group, LLC, its funding sources, agents and/or assigns are hereby authorized to obtain information in relation to my case, in order to determine consideration of this advance.

My typed name below, is my electronic signature confirming I agree with this statement, and that all information in this application is true and correct.

Additional Comments

Certification

I certify that I have spoken with my Attorney and he/she supports me applying for a Lawsuit Advance. I also certify that all information provided is true and accurate to the best of my knowledge. I authorize First Capital Financial Group, LLC, its Funding Sources, Agents and/or Assigns to contact me regarding my application. My typed name below is my electronic signature.

Today's Date

First Name

Last Name

Have Questions?

We're Here to Help Every Step of the Way

If you have any questions about the application process or need assistance, our funding specialists are standing by to help.

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