Opt-In Form – Opt In Form

Law Clinic Opt-In Form (#5)

Pre-Fix

First Name

Last Name

Phone 1

Phone 2

Address

Investment Advisor/Firm Name/Scam Name

Claim Type

Amount Lost

Method of Payment

Name of Bank/Building Society/Credit Card Provider

Have You Claimed Before ?

Yes

Please attach any evidence below

Choose File

Please give a brief description of what happened

By ticking the box above you are consenting to being contacted by telephone/email/post from a representative of Quick Start Claims. This is required to provide a regulated ‘no win no fee’ claims managment service.

Please tick this box to ‘Opt-In’