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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 FORM AND DISCLOSURE AUTHORIZATION

*Denotes required fields

I. CLAIMANT INFORMATION
*Name:
Address: City:
State: Zip:
Day Phone: Evening Phone:
Cell Phone: *E-Mail:
Marital Status:
Y N
Years Married: NO. of Children:  

Ages of Children:

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

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

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

If so, please describe:
Employer at
Time of Accident:

Phone:
Job Description:

Monthly Income:

Years on Job:
Address: City:
State: Zip:
Current Employer: Phone:

Are you currently out of work because of the injuries?:
Y N
How much time did you miss work because of the injuries? (No. of WEEKS):

II. CLAIM-RELATED INFORMATION
Amount Requested:

Range of Claim:

Date of Accident: MM/DD/YYYY
Location of Accident: Witnesses:
Y N
Brief Description
of Injury:
Similar Injuries/ Similar Physical Ailments Prior to Accident:
Description of Accident:
Defendant(s):
Insurance Companies and Policy Limits if known:

Have you ever filed another injury claim prior to the current action?:
Y N
If yes please provide injury, date, and result of action:

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?
Y N

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: Example: 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.

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