PICA - Intake Form

Our funding partners are currently at capacity, so processing times are indefinite. We'll contact those in queue when capacity opens—explore alternatives in the meantime. Learn More

Important Notice: Funding Pause

Thank you for your interest in Personal Injury Claim Advance. Our team is currently pausing new funding applications as our lenders have reached capacity.

We are actively working to free up capital and bring on additional lenders. Once opportunities arise, we will reach out to you directly to discuss if this is still a desired avenue for your needs.

The estimated timeline for resuming is unknown at this time, but we prioritize applications in the order received. By submitting this form, you acknowledge this pause and consent to us contacting you when funding becomes available.

Note: Submitting this intake form does not guarantee funding but places you in our queue.

I understand and acknowledge the funding pause. Proceed to intake form.

Identification

Contact

Lawyer

Accident

Advance

Misc

Identification

Legal First Name* This field is required

Middle Name

Legal Last Name* This field is required

Suffix

Last 4 of SSN* Please enter exactly 4 digits

Contact Information

Email* Please enter a valid email address

Phone* This field is required

Facebook ID (optional)

Preferred Method of Contact* Please select a contact method

Address Line 1* This field is required

Address Line 2

City* This field is required

State* Please select a state

ZIP* Please enter a valid 5-digit ZIP

Lawyer Information

Do you have a lawyer?* Please select an option

Incident Information

Police Report / Case Number

Type of Personal Injury* This field is required

Location of Incident* This field is required

State of Incident* Please select a state

Short Description of Incident* This field is required

Brief Description of Injury* This field is required

Outline of Treatment Received* This field is required

Advance Request

Expected Settlement Amount

Desired Claim Advance Amount* This field is required

Intended Claim Use* Please select an option

Is this your First Advance?* Please select an option

Insurance & Other Details

Your Insurance Provider* This field is required

Per Person Limit* Please enter a valid number

Per Accident Limit* Please enter a valid number

Other Party Insurance Known?

Was a Rideshare involved?