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FAQ
Home
Loan Process
Our Rates
Apply Now
Contact Us
FAQ
Lawyer APPLICATION
You're one step closer to receiving your loan! Please have your lawyer fill out this form and we'll get back to you as soon as we can.
Download Application PDF
Or fill out this online application below.
Lawyer's Name
Law Firm
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Fax
(###)
###
####
Email
Client
Date of Birth
MM
DD
YYYY
Client Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Client Tel.
(###)
###
####
Client Cell
(###)
###
####
Amount of Loan Request
$
Date of Loss
MM
DD
YYYY
File No.
Type of Claim
MVA
Slip and Fall
Are you the first law firm handling this file?
Yes
No
If no, indicate previous lawyer and/or law firm.
Accident Benefit Claim
Yes
No
Settled
Tort Claim
Yes
No
Is the client in the Major Injury Guideline (MIG)?
Yes
No
Settled
Have the injuries been deemed catastrophic?
Yes
No
Employment status at the time of the accident:
Employed full-time
Employed part-time
Self-employed
Unemployed
Student
Receiving social assistance and/or disability benefits
Gross annual income (approximate):
$
Is the client receiving IRBs (Income Replacement Benefits)?
Yes
No
Date IRBs terminated (if applicable):
MM
DD
YYYY
If yes, what is the weekly IRB amount?
$
Is the client eligible for or receiving Long Term Disability?
Yes
No
Is the claim associated with the Workplace Safety and Insurance Board?
Yes
No
Is liability/contributory negligence an issue?
Yes
No
If yes, please explain.
Has a Statement of Claim been issued?
Yes
No
If yes, date issued:
MM
DD
YYYY
If yes, Claim #:
Have Discoveries been scheduled or completed?
Yes
No
If yes, date of Discoveries:
MM
DD
YYYY
Has Mediation been scheduled or completed?
Yes
No
If yes, date of Mediation:
MM
DD
YYYY
Has a pre-trial been scheduled or completed?
Yes
No
If yes, date of pre-trial:
MM
DD
YYYY
Has a trial date been scheduled?
Yes
No
If yes, date of trial:
MM
DD
YYYY
Have any formal Offers to Settle been made by the Defence?
Yes
No
If yes, please specify the most recent amount:
$
Please describe the injuries the client sustained as a result of the incident.
Available Documentation:
Pleadings
Police Report
Hospital Records
Clinical Notes and Records
IMEs
Medical Legal Reports
Defence Medicals
Tax Returns
Employment Records (OCF2, contracts, offers of employment)
Will there be a claim for income loss/loss of competitive advantage in tort?
Yes
No
Assignments on File
Does the client have any assignments on file including legal files, medical expenses, social assistance, or any other settlement loans?
Yes
No
If yes, please elaborate:
Is the client undergoing bankruptcy proceedings?
Yes
No
Please inform us of any other information you feel is relevant.
Thank you for your application.
