Referral Form

Has your client already received funding through ClaimAngel on their case? Click Here
Portal

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Client's Name*

First NameLast Name
Client's Email*
example@example.com
Client's Phone Number*
Please enter a valid phone number.
Claim Type*
Please describe your role*

LawyerParalegalCase ManagerIntake SpecialistLegal AssistantClient Experience ManagerOther
What is your name?*

First NameLast Name
What is your email?*
example@example.com
What is the Lawyer's name?*

First NameLast Name
What is the Lawyer's email*
example@example.com
Your File Number
Has attorney been made aware of this funding request?*

YesNo
Would you like to provide case information in order to speed up the funding process?*

YesNo
Is the Case in Pre-Litigation, Litigation, or has it Settled?

Pre-LitigationLitigationSettled
Are there any offers on the case?

YesNoOther
Most Recent Offer ($)
Please Type A Dollar Amount
Please provide any notes on the offer
What Type of Funding Is This?

Pre-SettlementPost-SettlementMedical/Surgery FundingOther
Please attach the medical billing invoice if applicable

Cancelof
Date of Incident/Loss*

MonthDayYear
What State is the Claim Filed In?
What State is the Claim Filed In?*
How did the incident happen? Please include detailed information on injuries (soft tissue, herniations, tears, fractures, etc.)
Case Style / Case Caption*
Example: John Doe vs. Jane Doe Trucking
Has there been an Admission of Liability?

YesNoOther
Treatment to Date (Check all that Apply)

Hospital (Self-driven)Hospital (Ambulance)Serious Injections (Epidurals etc)Chiropractic CareSurgeryN/AOther
Insurance Info
Insurance Policy Limits
Example: $1,000,000
Insurance Carrier
Example: State Farm
Additional Insurance Info (Optional)
Example: BI $100,000/$150,000 or UM $200,000
Has the Claimant received any other pre-settlement funding or cash advances?

YesNoUnknown
Previous Funding Information
Is there a limit to the amount of funding the client should receive?

YesNo
If yes, what is the limit?
Please type a dollar amount
Link to Files (Dropbox, Onedrive, etc.)
Upload Documents

Please include an incident report, medical records (especially if there is surgery), settlement offers, and dec pages. You can submit multiple files.
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Additional Notes
Please add any additional information if you would like.
Should be Empty:

Has your client already received funding through ClaimAngel on their case? Click Here