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Applicant Information
All fields marked with an asterick (*) are required.
Who is completing this form?
Applicant
Representative of an applicant
Loan Amount Requested1 ($)
Loans starting at $500
First Name
Middle Name
Last Name
Address
Apartment/Suite Number
City
Province
Please select...
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewen
Yukon
Postal Code
Email Address
Phone Number
Have you ever changed your legal name by marriage or otherwise?
Yes
No
Date Of Birth
Accident Details
Please provide us with the details of your accident(s) or occurrence(s)
Type of Occurrence
Please select...
Motor Vehicle Accident
Slip & Fall
Long-Term Disability
Sexual Abuse
Product Liability
Other
Date of Occurrence
Province
Please select...
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewen
Yukon
Is this a WCB/WSIB/WorkSafe Claim?
Yes
No
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?
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Lawyer
Friend
OnLine
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Social Media
Other
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.
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