Capital Transactions :: personal injury funding for victims awaiting lawsuit

Pre-Settlement Funding
Financing Justice®

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About Our Pre

Worker's Compensation Application ©

Please note that we do not invest in cases in the following states:

Alabama
Arizona
California
D.C.
Florida
Idaho
Illinois
Kansas
Kentucky
Maryland
Michigan
Mississippi

Missouri
Montana
Nebraska
Nevada
New Jersey
New York
Oklahoma
Oregon
South Carolina
Tennessee
Texas
Virginia

Broker Code (if applicable):

Step 1. Client Information
Full Name:		Email Address:
Address:		Apartment/Suite:
City:		State:	Zip:
Home Phone:		Work Phone:
Date of Birth:		Education:
Children Living at home?:	Yes No	Occupation:
Employer:		Seniority Date:
How much money are you applying for?	$	Use of Funds:

Step 2. Event/Accident Description
Event Date:		Claim Date:
Describe what happened:
Where did the event happen:
City:		State:
Were there witnesses:	Yes No	When did you report the accident to your supervisor?:

Step 3. Injuries/Damages
Physical Damages
What damages did you suffer as a result of the accident:
Future Treatment Describe:
I have reached MMI (Maximum Medical Improvement)	Yes No

Step 4. Lost Wages
Dates you were unable to work:	From:	To:
Have you returned to work: Yes No	Were you out of work continuously between these dates? If not, explain:
Days lost from work:	Wages: $ --- Per:	Hour Day Week Bi-weekly Month Year
Wages Other:

Step 5. Disability
Extent of disability:	Temporary Permanent Partial Permanent Total None
Disability Rating:
Date of Rating:
What part of your Body is disabled:
Have you applied for Social Security Disability:	Yes No

Step 6. Attorney Information
Name:	Firm:
Address:	Address 2:
City:	State:	Zip:
Telephone:	Fax:
Paralegal:

Step 7. 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:
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.
CapTran Holding LLC Copyright 2000 - 2006
CapTran SC, LLC • CapTran NC LLC • CapTran DE LLC

Pre-Settlement Funding Financing Justice®

Pre-Settlement Funding
Financing Justice®