Initial Screening Form Fill out the following information to submit an application for legal fee acceleration! Step 1 of 4 25% How did you hear about us?Attorney/Law Firm InformationAttorney's Name*Law Firm*Firm's Street Address* Street Address (incude Suite #) City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Attorney's E-mail Address* Office Phone #*States of Admission to Bar* Funding InformationTotal Attorney Fees*Total Cost Reimbursement*Amount Requested to be Accelerated* Insurance Company InformationIndicate the following regarding insurance company issuing settlement proceeds.Insurance Company*Insurance Company Claim #*Adjustor's Name*Adjustor's Phone #* Settlement InformationSettlement Date* Date Format: MM slash DD slash YYYY Total Settlement Amount*MiscellaneousTitle of Action*Provide complete Title of Action with index number and CourtAre there any outstanding judgements or IRS tax liens against the applicant?*YesNoHas the applicant been or is the applicant currently involved in a bankruptcy or insolvency proceeding?*YesNoHas the applicant sought or received funds from any other funding company?*YesNoPlease check the box to help us prevent spam submissions. Thank you. This iframe contains the logic required to handle Ajax powered Gravity Forms.