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Dear Client,

Please fully complete this application to the best of your ability. Answer all appropriate questions on this application even if it is a negative issue. You will want to let your new Funding Source know as much as possible. Our job is to help you get the cash you need. Any negative issues are not intended to disqualify you, but to allow us to confront these issues head on. So be accurate and truthful to the best of your knowledge. This is very important. You don't want to waste time, slow down your application, or not receive a quote at all!

Upon completion and submission of this form, you will receive an immediate email with your confirmation and funding source information. Please add “globalquickcapital.com” to your allowed email to ensure delivery.

Please note that these Applications are for conducting cash flow business or applying for loans only! These are not job applications!


Thank you,
GlobalQuick CAPITAL

Attorneys Medical Procedure Funding Application

Requirements

  • Minimum: $1,000
  • No Maximum
  • Accepted Locations: U.S.A
  • Adults 18 and over only

Contact


Contact First Name:

Contact Last Name:

Title:

Email Address:

Phone Number:

Fax Number:

Cell Number:

Attorney Information


Law Firm:

Lawyer:

Paralegal Assigned:

Address 1:

Address 2:

City:

State:

ZIP Code:

Phone Number:

Cell Number:

Fax Number:

Incident Information


Date of Incident:
  

Case Type:
 Auto
 Medical Malpractice
 Workers Comp
 Premises Liability
 Assult
 Other

If other, give type of incident:

Case Details:

Extent of Injuries:

Incident Background


Number in Vehicle:

Driver or Passenger?
 Driver   Passenger

Surgery:
 Yes   No

Approximate Medical Costs to Date:

Are Medical Bills Paid:
 Yes   No

Medical Bills Paid by:
 PIP   Liens on Case   Other

Approximate Property Damage:

Approximate Lost Wages:

Approximate Workers Comp Liens:

Approximate Legal Expenses:

Other Incidents


Other Accidents:
 Yes   No

Prior Injuries:
 Yes   No

Subsequent Injuries:
 Yes   No

Child Support:
 Yes   No

Loss of Work:
 Yes   No

Criminal Record:
 Yes   No

Alchohol or Drug Use:
 Yes   No

Other Advances:
 Yes   No

Advance Amount:

Date Advance Taken:
 

Medical Provider


Name of Doctor:

Practice Name:

Address 1:

Address 2:

City:

State:

ZIP Code:

Phone Number:

Fax Number:

Date of Planned Surgery:
  

Type of Surgery:

Case


Theory of Liability:

Estimated Settlement Date:
  

Estimated Settlement Range:

Estimated Trial Date:
  

Estimated Verdict Range:

Settlement Offer:
 Yes   No

Settlement Amount:

Demand Letter:
 Yes   No

Demand Amount:

Approximate Property Damage:

Approximate Lost Wages:

Approximate Workers Comp Liens:

Approximate Legal Expenses:

Sources of Recovery


Defendant 1:

Insurance Company:

Coverage:

Claim Number:


Defendant 2:

Insurance Company:

Coverage:

Claim Number:


Defendant 3:

Insurance Company:

Coverage:

Claim Number:




Plaintiff 1:

Insurance Company:

Type:
 Full Tort
 Limited Tort
 Underinsured
 Uninsured

Coverage:

Claim Number:


Plaintiff 2:

Insurance Company:

Type:
 Full Tort
 Limited Tort
 Underinsured
 Uninsured

Coverage:

Claim Number:

Documents


Documents in your possession:
First Doctors Visit
ER Report
Operative Reports
MRI/X-Ray Reports
Expert Report
Police Report
Accident Report
Complaint
Determination of Complaint
EEOC

Client Information


What is your motivation?

How much cash do you need or want?

Date Needed:
 

Comments


Additional Comments:

How did you hear about GlobalQuick CAPITAL?

Who Referred You?


No one referred me:

Referred Name:

Referred Phone:

Referred Email:

Application Id:
20240424-215242-328

Please note:
The Funding Source may require copy of additional documents
to make your quote. They will let you know by Email.


Upon submission of this form, you will receive an immediate email with your confirmation and funding source information. Please add “globalquickcapital.com” to your allowed email to ensure delivery.


Privacy Policy & Security

Apply online for a free no obligation quote: Response in 24 to 48 hours in most cases. Our funding sources will be happy to answer all your questions at that time!

We are proud members of the cash flow/growing wealth industry.

We are a
green
company!

We at GlobalQuick CAPITAL believe in giving back to help in this world! A portion of the profits from our earnings will be given to: Heart Research, Arthritis Research, Endangered Animal Species, and Rain Forest Preservation.