ONLINE APPLICATION:

Please fill out as many of the fields that apply to your situation as possible. Asterisks denote required fields.

Personal Information:












Attorney Information:











  • Yes No

  • Yes No
Incident Information:






  • Yes No N/A

  • Yes No N/A

  • Yes No N/A
Injury Information:



  • Yes No


  • Yes No

  • Yes No

  • Yes No

  • Yes No

  • Yes No

  • Yes No



Wage Loss Information:





Release of information authorization:

By submitting this form, I certify that the information is true, and I authorize my attorney to release information to Lifeline Legal Funding LLC for the purpose of evaluating my funding request.

  • NO Risk / NO Obligation Application
  • NO Pressure to Settle Your Case Early
  • NO Credit Check
  • NO Up-Front Fees
  • NO Employment Requirement
  • NO Payment Until Your Case Settles
  • NO Payment If You Lose Your Case
  • NO Involvement With Case Management
  • Fast and Easy Application & Approval
  • Highly Competitive and Simple Pricing
  • Ultra-Convenient Electronic Signing
Quick Contact Form

If you would rather apply by phone, please complete the short form below and we will be happy to call you.

Asterisks denote required fields.