Claimant Application

Please fill out as much of the form below as you can. Except where indicated, leave blank any questions you cannot answer. We can get additional information from you and your attorney later. If you’re having trouble with this application, call and we’ll take your application over the phone.

Claimant Application


Ineligible States:
Alaska, Arizona, Arkansas, Colorado, District of Columbia, Hawaii, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, North Carolina, Oklahoma, Rhode Island, South Dakota, Tennessee, West Virginia, Vermont


LAWYER CONTACT INFORMATION


CASE INFORMATION


YesNo


PRIOR LIEN INFORMATION


YesNo