Application Form

Applicant Information

All fields marked with an asterick (*) are required.

Who is completing this form?

ApplicantRepresentative of an applicant

Loan Amount Requested1 ($)

Loans starting at $500

First Name

Middle Name

Last Name

Address

Apartment/Suite Number

City

Province

Postal Code

Email Address

Phone Number

Have you ever changed your legal name by marriage or otherwise?

YesNo

Date Of Birth

Accident Details

Please provide us with the details of your accident(s) or occurrence(s)

Type of Occurrence

Date of Occurrence

Province

Is this a WCB/WSIB/WorkSafe Claim?

YesNo

Lawyer Details

Please provide us with the contact information of your lawyer.

Lawyer First Name

Lawyer Last Name

Law Firm

Lawyer Email

Phone Number

Contact at Law Firm other than lawyer (if applicable)

How did you hear about BridgePoint?

I certify and declare that the information set out in this Application is true, accurate, and complete. I warrant and acknowledge that the contents of the Application will be relied upon by BridgePoint Financial Services ("BridgePoint") in assessing risk, offering any terms, and providing any loans and will be the basis of and form part of any resulting loan offered by BridgePoint to me. I authorize and provide BridgePoint with the necessary consent to independently verify the accuracy of this information for the purpose of evaluating my application, including speaking with, and receiving documentation on my file from, my lawyer. I consent to the collection, use, and disclosure of my personal information by BridgePoint for the purpose of evaluating and considering my application for BridgePoint's products and services.

Contact Information