Loan & Claim Details

Enquiry Form
Primary Contact Details
Name*

TitleFirst NameMiddle NameLast Name
Primary Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com

Thanks for that, And now for some important legal disclosures.

We take our obligations as a lender seriously, so here’s some vital information you need to know about how we work, how we can communicate with you and how we deal with your personal information, including credit reporting. Please call us if you require assistance with this application 1300-452-999

Loan & Claim Details
Law Firm Name*
Solicitor Name*
Solicitor Email Address*
example@example.com
Solicitor Phone Number*
Please enter a valid phone number.
Amount you are requesting? ($5,001-$25,000)*
Date of accident*

DayMonthYear
Date
Has your claim been settled?*
Settlement Date if YES or Estimated Settlement Date if NO*

DayMonthYear
Date
Type of claim (Workcover/Motor Vehicle/TPD/Public Liability)*
If settled, please upload copy of Deed of Release

Cancelof
If settled, "Settlement Amount; if not settled, "Estimated settlement amount"*
Purpose of the loan*
Have you received other funding advances ?*
If YES to other funding advances, please advise amount

Your Personal Details
Date of Birth*

DayMonthYear
Date
Start of tenancy at current residence*

DayMonthYear
Date
Street Address*
City*
Street Address 2
Postcode*
State*
Secondary Phone Number
Please enter a valid phone number.
Marital status*
Number of dependants*
Landlord/Mortgagor Name*
Landlord/Mortgagor phone number*
Please enter a valid phone number.

Statement of Position

Asset

	Amount $
Cash/Term Deposit
Property 1
Property 2
Motor Vehicle 1
Motor Vehicle 2
Other

Total

Liability Type

	Description/Address	% Ownership	Amount $
Short Term Loan
Credit Card 1
Credit Card 2
Credit Card 3
Mortgage 1
Mortgage 2
Car Loan 1
Car Loan 2
Other

Ownership Total
Amount Total

Annual Income

	Amount $
Wages
Centrelink
Rental income
Other income

Total

Annual Expenses

	Amount $
Loan Repayments
Rent/Board/Mortgage
Gas/Electricity
Water Rates
Phone/Internet
Mobile Phone
Groceries
Personal expenses
Child Expenses
Entertainment
Medical Expenses
Insurances
Vehicle Expenses
Other Expenses

Total

Disclaimer & Signature
"I (client name) blanks am applying for a settlement advance from First Republic Finance Pty Ltd ABN 67 128 694 119 ACL 387339 trading as Lawzy (the Lender).

I hereby authorise (Law Firm name) blank to disclose information about my claim to the Lender so that they can make reasonable inquires and comply with their responsible lending obligations under the National Consumer Credit Protection Act 2009”
I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application may result in termination of application.
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