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Law Suit Loans for the Injured and Disabled
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Application Form
Lawsuit & Settlement Application Form
Complete our confidential loan application form to get the process started.
Personal Information
Loan Amount Requested
*
First Name
*
Middle Name
Last Name
*
Address
*
Street Address
Apartment Number
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone
*
Fax
Mobile Phone
Email
*
Date of Birth
Occupation
Annual Salary
Are you collecting any type of benefit?
Yes
No
Who is paying you the benefit?
Amount of Benefit
Do you already have a law suit loan from another company?
Yes
No
Name of loan company
Amount of Loan
Have you been declared Bankrupt or are you undergoing Bankruptcy proceedings?
Yes
No
Type of Lawsuit
Type of Lawsuit
*
Disability Claim
Employment/Dismissal
Motor Vehicle Accident Claim
Slip & Fall Accident
Other
Disability Claim
Name of Insurance Company
Type of Insurance
Group LTD Policy (through employment)
Private Insurance Policy
Critical Illness
Other
Amount of Monthly Benefit
Have you also made a claim for WSIB Benefits?
Yes
No
Tell us about your case
Employment/Dismissal
What was your date of hire?
*
What was your date of termination?
*
What is/was your Position?
*
What is/was your total compensation?
*
Was there a dismissal?
Yes
No
Are you a member of a Union?
Yes
No
Motor Vehicle Accident Claim
Date of Accident
Who is at fault for the accident?
Yourself
Another Driver (identified
Don't Know
Who is at fault for the accident?
Yourself
Another Driver (identified
Don't Know
Injuries that you suffered
Are you currently working?
Yes
No
Tell us about your case
Slip & Fall Accident
Date of Accident
Did the accident happen at work or while you were working?
Yes
No
Did your accident happen on municipal property such as sidewalk or roadway?
Yes
No
Injuries that you suffered
Are you currently working?
Yes
No
Tell us about your case
Other
Tell us about your case
Lawyer's Contact Information
Law Firm
*
Lawyer's Name
*
Email (Lawyer or Law Firm Contact)
Lawyer's Telephone
*
Lawyer's Fax
How did you hear about Lifeline
Internet Search
Friend/Family
Lawyer
Other
*
I hereby acknowledge that the information provided to Lifeline in this application is true, and accurate. I authorize and provide Lifeline with the necessary consent to independently verify the accuracy of this information for the purpose of reviewing my loan application. I authorize my lawyer noted above to provide Lifeline with all relevant information regarding my legal claim.
