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:

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:

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:

20241121-022359-330

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.