Double ii's Services/Advance Lawsuit Funding Secure Attorney/Client Funding Request Form

Have the following documents if available/applicable (bold are required), to send/fax us once we contact you:
Police/Incident/Accident Report
Hospital/Emergency Room Reports
Medical Reports, Physician's Assessment
Medical Bills/Statements, Summarized
Demand Letter
Settlement Offer, if made
Summons/Complaint
Interrogatories, Depositions, Pleadings
Witness Statements
Expert Witness Statements
Expert Discovery (for Malpractice)

Double ii's Services/Advance Lawsuit Funding Secure Attorney/Client Funding Request Form - see requirements and restrictions here. Please fill out as much as possible, as it applies to the case. The field will keep scrolling as you fill it in. All information is kept strictly confidential.

Client First/Last Name
Client Address
City
State
Zip/Postal Code
Country - needs to be U.S. or a U.S. territory
Daytime Phone
Evening Phone
Best Time to Call
Email Address
Social Security Number (if comfortable)
Birth Date
Attorney Name
Name of Attorney's Firm
Attorney Phone Number
Attorney Fax Number
Attorney Address
Who Send Fax To (name of paralegal, for instance)?
What type of case is this (auto, personal injury, slip/fall, malpractice, etc.)? What happened?
What is the date of the incident?
What is the location of the incident?
Injuries and damages? Fractures, etc.
What is the location of the incident?
Describe medical treatment. MRI? Surgery (when)? Hospital stay?
Are you still under treatment? Explain.
Date of initial doctor visit?
Policy limits and insurance company of defendent?
Client's insurance company?
Is the case settled?
Has the lawsuit been filed yet? When?
Has a settlement offer been made? How much?
Is this in mediation or on schedule for mediation?
Has a demand letter been sent? How much?
Is this out on appeal?
Is liability clear or admitted?
When is it supposed to settle or pay?
Why wouldn't this case settle?
What is the estimated value of the case?
Requested punitive and/or compensatory damages, if any?
How much of an advance is needed? Minimum amount?
What are the monetary damages? Lost wages?
What is the amount to be awarded or estimate of settlement?
When is it looking to settle or go to trial? Estimated date of settlement?
What is the amount of the medical bills/damages to date?
Has client reached maximum medical improvement?
What are your thoughts about the case?
Is there a previous advance? How much? What company?
Are there liens against this settlement? Please elaborate (amount, type).
Is there a bankruptcy in process?
How fast is the advance needed?
Has client returned to work? When?
Previous WC claims, preexisting conditions, previous injuries.
Is this case on a contingency fee basis? Percentage?
Costs to date (medical, case preparation, lost income)?

Any Comments & Special Instructions. Tell us anything more you want us to know about about the lawsuit or situation.
 

   
 
 
If you have any questions, send an email.

Double ii's Services/Advance Lawsuit Funding
PO Box 631746
Highlands Ranch CO
80163-1746
303-220-5679
Funding Options