GOLDEN PEAR (GP) CLIENT LEAD FORM

ABOUT THIS FORM

Please fill out as much information on this form as possible. This application will be forwarded to our broker program team who will request information from the attorney and process with underwriting department. This team will also manage the client, so please provide them with the Golden Pear contact information. The broker will be notified when the client has been funded and receive a percentage of the funded amount. To inquire about the status of your client lead please call Golden Pear Funding at 212-244-8200 and ask for the broker department.

BROKER INFORMATION FIRST NAME: LAST NAME: CLIENT INFORMATION FIRST NAME: LAST NAME: DATE OF BIRTH (MM/DD/YYYY): / / HOME PHONE (XXX-XXX-XXXX): CELL PHONE (XXX-XXX-XXXX): EMAIL ADDRESS:

ATTORNEY INFORMATION FIRST NAME: LAST NAME: OFFICE PHONE (XXX-XXX-XXXX): FAX NUMBER (XXX-XXX-XXXX): CASE INFORMATION TYPE OF CASE: MVA Slip & Fall Premise Product Liability Medical Malpractice Settled Other ACCIDENT DATE: