Call Us Today: 585-225-2431

Home
About Us
Eligible Claims
FAQs
Application
Contact Us

Apply Now

APPLY NOW

Please complete and submit the following application. A representative will contact you shortly after your application is received. If you would prefer to fill out a printed version of this form and mail it to Juris Investments click here to download and print our application. (Acrobat Reader Required)

Application From And Disclosure Authorization

*Denotes required fields

Application From And Disclosure Authorization

Free Text

I. CLAIMANT INFORMATION

Name:

Address:

City:

State:

Zip:

Day Phone:

Evening Phone:

Cell Phone:

E-Mail:

Marital Status:

Yes

Years Married:

NO. of Children:

New Field:

Are there any outstanding judgments or liens against you or this case, including any other advances on this case?

Yes

If yes please list name of lien holder(s) and amount(s):

Have you ever been involved in any bankruptcy or insolvency proceeding?

Yes

If so, please describe:

Employer at Time of Accident:

Phone:

Job Description:

New Field:

Years on Job:

Address:

New Field:

State:

New Field:

Current Employer:

New Field:

Are you currently out of work because of the injuries?:

Yes

How much time did you miss work because of the injuries? (No. of WEEKS):

Free Text

II. CLAIM-RELATED INFORMATION

Amount Requested:

Range of Claim:

Date of Accident:

Location of Accident:

Brief Description of Injury:

Similar Injuries/ Similar Physical Ailments Prior to Accident:

Description of Accident:

Defendant(s)

New Field:

If yes please provide injury, date, and result of action:

Witnesses:

Yes

Have you ever filed another injury claim prior to the current action?:

Yes

Free Text

III. ATTORNEY INFORMATION

Attorney Name:

Law Firm:

Address:

City:

State:

Zip:

Phone:

Fax:

E-Mail:

Date Retained:

Co-Counsel and Phone Number, if applicable:

Is the attorney handling more than one case for you?

Yes

Statement of Affirmation and Disclosure Authorization

Statement of Affirmation and Disclosure Authorization

By signing and submitting this form, (1) I agree that all information listed is complete and accurate to the best of my knowledge and (2) I hereby authorize the attorney and law firm listed above (Attorney), and waive the attorney/client privilege for the sole purpose of enabling Attorney, to release to Juris Investments any information requested regarding my claim including information concerning the nature, background, and details of my claim and an opinion by Attorney concerning the status and progress of the claim, the likelihood of success on the claim, and the range of probable recovery. I specifically waive any privilege that I may have in this regard.

This information is for the confidential use of Juris Investments in making a determination of whether to advance funds to me as an investment in my claim. These funds will provide me with the necessary financial assistance until my claim is resolved.

By marking the box below and submitting this form I affirm that all the information

provided in the Application is complete and accurate in good faith and to the best of my knowledge.

I understand that I am under no obligation at any time prior to receiving a cash advance.

SIGNATURE SECTION FOR ELECTRONIC VERSION

Enter your FULL NAME here:

Enter TODAY’S DATE here: MM/DD/YYYY

By marking the box you acknowledge that you have read, understand and agree to the Disclosure Authorization allowing your attorney to share records in connection with you claim. This box must be checked in order to begin the process of reviewing your request for a cash advance. This gives us permission to contact your attorney and discuss your case with the attorney.

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Contact Juris Investments

Sound legal advice is based on years of training, hard work, and passion, as well as familiarity with legislation and precedent and sound consideration. You’ll find all that and more at Premium.

Thank you for contacting us.
We will get back to you as soon as possible

Oops, there was an error sending your message.
Please try again later

About Us

Juris Investments is a niche investment company that provides non-recourse advances to accident victims with pending personal injury and negligence cases.

Contact info

Juris Investments

PO BOX 26914
Rochester, New York 14626

585-225-2431

donna@jurisinvestments.com

Map

{ Site Creation by Motorhead Digital }