Capital Transactions :: personal injury funding for victims awaiting lawsuit

Pre-Settlement Funding
Financing Justice®

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About Our Pre

Federal Employer's Liability Act - FELA ©

Fill out as much information as possible. We will obtain missing information from your attorney.

(CapTran does not invest in cases whose basis of venue and/or residence of claimant is Alabama, Alaska, District of Columbia, Georgia, Indiana, Iowa,Kentucky, Louisiana, Michigan, Missouri, Montana, Nevada, Ohio, Rhode Island, South Dakota, Utah, Vermont, Wyoming.)

Broker Code (if applicable):

Step 1. Personal Information

Victim's Full Name:

Email Address:

Address:

Apartment/Suite:

City:

State:

Zip:

Home Phone:

Work Phone:

Date of Birth (mm/dd/yyyy):

Education:

Children Living at home?:

Yes No

Occupation:

Employer:

Seniority Date:

How much money are you applying for?

Use of Funds:

Step 2. Event Description
Event Date (mm/dd/yyyy):		Describe what happened:
Where did the event happen:
City:		State:
Were there witnesses:	Yes No	When did you contact your Union Representative?:

Step 3. Injuries/Damages
Physical Damages
What damages did you suffer as a result of the event:
Future Treatment Describe:
I have reached MMI (Maximum Medical Improvement)	Yes No
Lost Wages
Days lost from work:
Wages:
Per	Hour Day Week Bi-weekly Month Year
Disability
Extent of disability	Temporary Permanent Partial Permanent Total None
Disability Detail
Are you currently receiving disability benefits:	Yes No

Step 4. Attorney Information
Name:	Firm:
Address:	Suite:
City:	State:	Zip:
Telephone:	Fax:
Paralegal:	Phone:

Step 5. Records Release Authorization
In order to obtain information about your case you provide your attorney with authorization to release your case records and information to us. We cannot proceed without it.
Dear Enter your Attorney’s name here:
I hereby request and authorize your firm to cooperate and release to Capital Transaction Group Inc (Captran) any and all information and documents pertaining to my current case. I additionally ask that you share your candid opinion regarding this action with the above firm. I acknowledge that I understand the benefits of non-recourse funding. I further acknowledge I understand the effects of disclosing the contents of my file, including waiver of the attorney-client and work product privileges. Thank you in advance for your cooperation in this matter.
Enter Your Full Name Here:
Enter Today’s Date Here (mm/dd/yyyy):
By clicking here you indicate that you have read and agree to the Records Release Authorization. You must check this box to have your application processed. This gives us permission to contact your attorney and review your file. All information is held strictly confidential.

Disclaimer: The material published at this site is for informational purposes only and is not intended to be legal advice. Transmission of the information is not intended to create, and receipt does not constitute, an attorney-client relationship between any parties whatsoever. Readers, whether or not attorneys, should not act upon this information without seeking professional advice or doing independent legal research. CapTran disclaims any liability whatsoever for any consequences that may flow from any material published here.
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Pre-Settlement Funding Financing Justice®

Pre-Settlement Funding
Financing Justice®