Plaintiff Application

INTRODUCTION

Welcome. We have created this on-line application to make your life easier and to expedite your funding request. The application

gathers your information, emails it to us and also produces a summary page for your file. If you have any questions you can call

us at 888-718-0787. Please complete each field in the application below. If the information is not applicable or unavailable simply

insert "N/A" or "None". Please review the information you entered, and if correct click the "Submit" button at the bottom of page.

When you click the Submit button we receive the information by email and can start processing your application.

If any information needs to be revised please click your browser back button to go back to page to correct or add information.

Print

Once you click the "Submit" button you will get a transmittal page. Please print out copies of this page for confirmation for

your records.(The single web page should print out as three printed pages.)

Thank you,

MoniCore International

(If you would prefer to not apply on-line you can print out a hardcopy by clicking here, Print application and fill it in and

fax it to us at 805-581-5913 or overnight mail to us with the accompanying documentation.) Attn: Gregory C. Sanders

MoniCore International, 1645 Deodora St., Simi Valley, CA 93065. If you have questions call us at 1-888-718-0787

Plaintiff Application

General Information
Amount Requested: $
Client Information
Name:	*
Address:

City:
State:
Zip:
Date Of Accident:	/ /
Home Phone:	** xxx-xxx-xxxx
Work Phone:
Date Of Birth:	/ /
Social Security Number:	* xxx-xx-xxxx
(If Auto) Number of People in Host Vehicle:
(If Auto) Client a passenger or a driver?:	PassengerDriver
By when do you need the cash?:	/ /
What do you need the money for?:
Criminal Record Admissible In Evidence?:	YesNo
Alcohol / Drugs Admissible As Evidence?:	YesNo
Are You Paying Child Support?:	YesNo
Attorney Name:
Firm Name:
Address:

Phone:
Fax:
Details of Case:	AutoPremise AccidentMalpracticeCommercialOther
Explain:
Extent Of Injury's (Physical / Financial):
Cost To Date:
Medical:	$ Future $
Lost Client Income:	$ Future $
Have any settlement offers (verbal / written) been made::	$
Liens Filed To Date
Lien 1:	/ /
	Lien
	Amount
Lien 2:	/ /
	Lien
	Amount $
Lien 3:	/ /
	Lien
	Amount $
Has The Client Had The Following?
Surgery:	YesNo

Preexisting Conditions:	YesNo

Previous Injuries:	YesNo

Previous WC Claims:	YesNo

Has Client Returned To Work?	YesNo
If So, When:	/ /
The Following Must Accompany This Report To Be Considered For Funding: (Please, confirm by checking box)	Police / Accident Report Hospital / Emergency Rm. Reports MRI / X-RAYS / Medical Narratives