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 Documents To Be Submitted For Funding Request:

[1] Plaintiff to sign a Records Release Form (see item D below)

[2] Photocopy of Agreement with Attorney

[3] Photocopy of Police Report ( showing Plaintiff was not at fault)

[4] Copy of Medical Records (showing Plaintiff was injured ...if in accident)

[5] Proof that Defendant has insurance

[6] Copy of Lawsuit Papers.

[7] Signed Letter of Authorization from Plaintiff (Sample copy below)

[8] Plaintiff Funding Application  

Documents below in Microsoft Word:

 [] Records Release Form: Records & Information Release.doc

 [] Signed Letter of Authorization: Letter of Authorization.doc

 [] Plaintiff Funding Application: Plaintiff Funding Application.doc

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PLAINTIFF FUNDING APPLICATION         Account Number: 23502BP

Please print.  All information is strictly confidential.  No credit check is required. 

                             Fax completed form to: 305-663-9912

A.  CONTACT INFORMATION: 

Full name:	Date of Birth:
Home address:	E-mail address:
City, state:	Fax Number:
Zip code:	Social Security No.:
Phone number (day):	Phone number (evening):

B.  AMOUNT OF MONEY REQUESTED:

$	To be used for:

C.             LAWSUIT INFORMATION: 

        Attorney Information

Attorney Name:	Phone number:
Firm Name:	Fax number:
Address:	E-mail address:
City, state:	Zip code:

      Accident Information

Type of case:  (please circle all that apply)  Auto Accident     Slip/Trip and Fall     Premises Liability     Medical Malpractice    Workers Comp Third Party     Jones Act (Maritime)     FELA (Railroad)     Other

Your injuries:

Treatment (surgeries, etc.):

D.    RECORDS & INFORMATION RELEASE

Account Number: 23502BP   Dear Attorney _____________________________:   I, the undersigned, hereby request and authorize your firm to cooperate and release all necessary and requested information and documents pertaining to my current claim or lawsuit to American Institute.  I additionally request and instruct you to share your candid opinion(s) regarding my claim or lawsuit with American Institute, its representatives, affiliates and agents.   I understand that all information will be treated as privileged and confidential and will only be used in the limited capacity of of underwriting my claim in consideration for a financial advance and will not be further used or disclosed unless so instructed by myself, my counsel or a lawful court order.     _____________________________          ____________________ Signature                                                     Date

                                    Fax completed form to: 305-663-9912

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Account Number: 23502BP   LETTER OF AUTHORIZATION    Date   ATTORNEY NAME LAW FIRM NAME LAW FIRM ADDRESS   YOUR NAME YOUR COMPANY YOUR ADDRESS   Dear ATTORNEY NAME:   I request and authorize your law firm to release to American Institute or assigns any and all documents pertaining to my current case. This would include, but not be limited to: MRI Reports, Police Reports, Accident Reports, Emergency Room Reports, Surgical Reports, and Narrative.   I acknowledge that you assume no liability, offer no guarantees to American Institute. Thank you for your cooperation.   Sincerely   X____________________________________ CLIENT NAME     cc: YOUR COMPANY NAME Fax: YOUR FAX NUMBER

Fax Completed Documents to: 1-305-663-9912. Put this

Account code: 23502BP on All Docs for Priority Processing.