Interim Funding Inc

	Applicant Information ALL FIELDS REQUIRED EXCEPT AS NOTED WITH "*"
Name:
Address:
City:		State:	Zip Code:
Home Phone:		*Work Phone:	*Fax No.:
* E-mail Address:
Date of injury:
Nature of injury:

	Attorney Information .
Attorney's Name:
Address:
City:		State:	Zip Code:
Attorney's Phone::		Attorney's Fax No.:
Has a lawsuit been filed?		If Yes, when?	Where?
Is there a police report?		Is the defendant liable?	Does he/she have insurance?
Are there medical bills?		How much?	Future bills expected?
How did you find us?		Category Searched?