First Choice Legal Funding — Law-Firm Intake Form

For the requesting law firm: Please complete this form to request non-recourse pre-settlement funding for your client. Fields adjust automatically based on the case type you select below. When finished, click Generate Summary to produce a copy you can email to us, copy into your file, or print / save as PDF. Repayment is contingent solely on a recovery in the underlying case — if the case does not result in a recovery, the plaintiff owes nothing.

Fields marked * are required; others may be left blank if not applicable. Your progress is saved automatically in this browser until you submit or clear the form.

Case type * Selecting a type reveals the case-specific questions our underwriters require.

1 Requesting Firm

Identifies the firm submitting the request and the attorney of record we will route the Letter of Direction to.

Firm name *

Attorney of record (signing partner) *

Submitter name (if different)

Firm email *

Firm phone *

Firm mailing address

Have you funded with First Choice before?

Yes No

Date of submission

2 Plaintiff Biographical Information

The applicant is always the named plaintiff — never the attorney. Used for the biographical & lien search.

Full legal name *

Aliases / prior names (if any)

Date of birth *

Last 4 of SSN (if available)

Current address *

Prior addresses (last 7 years)

Telephone *

Marital status

Spouse name (loss-of-consortium claim, if any)

Occupation

Pre-loss employer

Citizenship / work-authorization status (if relevant to a wage-loss claim)

3 Case Facts

Date of incident *

Time of incident

Location of incident *

Plain-English narrative of how the incident occurred *

Case caption

Index / docket number

Court / venue

Filing date

All defendants and their relationship to the loss *

Co-defendants, third-party defendants, indemnitors (names & roles)

Status of pleadings

Complaint filed Answer served Bill of particulars served Depositions taken

Statute-of-limitations date *

4 Liability

Where the case sits on the liability spectrum drives the advance percentage.

Liability posture *

Admitted / Conceded Won by Motion (summary judgment) Strongly Favorable / Likely Contested Unknown / Not Yet Joined

If contested, summarize the defendant's liability defense

Is comparative fault alleged?

Yes No

If yes, firm's anticipated allocation (%)

MVA Motor Vehicle Accident — Case-Specific

NY MVA cases are subject to No-Fault (Ins. Law Art. 51) and the "serious injury" threshold (Ins. Law § 5102(d)).

Police report number (MV-104A or local)

MV-104 code

Citations issued

Criminal disposition (e.g., DWI conviction)

Plaintiff's SUM / UM / UIM coverage

No-Fault / PIP carrier

Serious-injury threshold category — Ins. Law § 5102(d)

Fracture Significant limitation Permanent consequential limitation 90/180-day rule

NF-2 / NF-3 on file?

Yes No

Vehicle damage / scene photos available?

Yes No

LABOR Labor Law (Construction) — Case-Specific

Signature provisions: NY Labor Law §§ 240(1) (Scaffold Law), 241(6) (Industrial Code), and 200 (safe workplace). WC lien under WCL § 29 is senior to the funder's lien.

Owners, GCs, construction managers, subcontractors (with proof of relationship)

Job-site location

Plaintiff's employer

Project description

Mechanism of injury (gravity-related fall / falling object for § 240(1))

Specific Industrial Code section(s) alleged — § 241(6)

Elevation differential

Pending MSJ on § 240(1) liability?

Yes No

Status of third-party action

Workers' Compensation — case #, carrier, indemnity rate, lien to date, projected lien at resolution

OCIP / CCIP info; certificates of insurance for GC and subs

Immigration / work-authorization concerns (if relevant to wage loss — Balbuena)

PREMISES General Negligence (Slip / Trip & Fall) — Case-Specific

NY premises cases turn on notice (actual or constructive) and the storm-in-progress doctrine for weather claims.

Incident report (store, building, MTA, NYCHA, etc.)

Property owner, tenant in possession, maintenance/cleaning contractor — with insurance for each

Notice analysis

Actual notice (prior complaints / work orders) Constructive notice (duration of defect)

Photos of the defect on/near date of loss?

Yes No

Surveillance / CCTV preservation status

Storm-in-progress / weather data (if weather-related)

Sidewalk case — 311 / Big-Apple Pothole pre-suit notice?

Municipal defendant? Notice of Claim (GML § 50-e) date & 50-h hearing status

GENERAL General Personal Injury — Case-Specific

Catch-all for matters such as assault, dog bite, medical malpractice, or products liability. (These files require Senior Underwriter co-sign.)

Identify every potentially liable defendant and every applicable policy (declarations pages where obtainable)

Liability assessment narrative (admitted / established / contested / unknown)

Medical narrative (diagnosis, treatment, surgeries, prognosis, projected future treatment)

Comparable-case research (verdicts / settlements in the same venue)

5 Insurance / Policy Information

Primary liability carrier *

Primary policy number

Per-occurrence limit

Aggregate limit

Excess / umbrella carrier

Excess attachment point & limit

Self-insured retention / deductible

Reservation of rights / coverage disclaimer?

Yes No Unknown

Most recent demand letter & carrier response (date / amount / status)

6 Damages

Diagnoses with ICD-10 codes *

Surgeries to date and recommended future surgeries

Treatment summary (PT, injections, pain management, psych)

Billed medical expenses to date

Out-of-pocket medical to date

Past lost earnings

Projected future earning loss

Life-care plan / vocational rehab report produced?

Yes No

Photographs of injuries / scene available?

Yes No

7 Liens / Claims Against Recovery

Every senior or co-equal lien must be disclosed — these compete with the funder at distribution.

Medicare / Medicaid (eligibility dates & conditional-payment summary, if available)

Private health-plan / ERISA reimbursement (plan name, administrator)

Workers' Compensation (case #, carrier, lien to date, projected lien)

Hospital / provider liens

Child-support obligations (state, case #, arrears)

Outstanding judgments / tax warrants / bankruptcies

Prior or concurrent litigation-funding advances (funder name, balance, payoff)

8 Funding Request

Amount requested *

Expected case-resolution timeline (months)

Anticipated use of funds (housing, medical, transportation, daily living)

Plaintiff's contact preference

Phone Text Email

Best times to reach the plaintiff

9 Documents Enclosed With This Request

Check each document you are submitting with this form. Underwriting cannot complete without the core items.

Police / incident report Photographs and any video Complaint & most recent pleading Bill of particulars Deposition transcripts Declarations pages (all policies) Medical records & imaging reports MV-104 / Notice of Claim / OCIP-CCIP cert Most recent demand & carrier response

✓ Firm Attestation

The information above is accurate to the best of the firm's knowledge, and the firm understands the plaintiff must execute First Choice's Funding Agreement, Authorization (HIPAA / credit / lien search), and the firm will sign the Attorney Acknowledgment & Irrevocable Letter of Direction via Adobe Sign before any advance is funded.

★ First Choice — Office Use Only

Matter ID

Date received

Conflict / OFAC check

Clear Flag

Firm on approved roster?

Yes Vetting

Assigned underwriter