Case Advance, Inc.

Case Advance Application Form
If you are looking to refer a friend, go here.

NAME:
ADDRESS:
EMAIL ADDRESS:
PHONE: HOME:		CELL PHONE:
DRIVER'S LICENSE NO.:		STATE ISSUED IN:
AMOUNT DESIRED:


TYPE OF CASE
	Auto Accident	Dog Bite	Assault	Trip/Slip/Fall
	Product Liability	Medical Malpractice	Wrongful Death	Other


DATE OF INCIDENT:

YOUR ATTORNEY’S INFORMATION:
Name:		Law Firm:
Address:
Phone:		Fax No:
SUIT FILED:	Yes No

Release of Information Authorization

Dear (your attorney’s name):

I hereby authorize and direct your firm to cooperate and release all necessary and requested information and documents pertaining to my current claim or lawsuit which occurred on (date of accident) to Case Advance and its representatives. I understand that all information will be treated as privileged and confidential and will only be used by Case Advance for purposes of advancing funds on my claim or lawsuit and that the information and documents pertaining to my current claim or lawsuit will not be disclosed or disseminated for any other purposes absent my written consent.

Thank you for honoring my request.

Signed: (full name)

Date: (today’s date)