Legal Auto Accident Intake Form

LEGAL AUTO ACCIDENT INTAKE FORM

This Legal Auto Accident Intake Form and Limited Retainer Agreement is entered into by and between Client Name: and Attorney/Firm Name: on Intake Date: .

RECITALS

WHEREAS, Client seeks legal representation related to injuries, property damage, and other claims arising from a motor vehicle collision described below; and

WHEREAS, Attorney is willing to evaluate and, if agreed, represent Client on the terms set forth herein and to take steps to investigate, preserve evidence, and pursue claims against third parties and insurers; and

WHEREAS, the parties desire to record Client's factual information, medical treatment, insurance details, and to set forth a limited retainer and authorization for handling records and settlement proceeds.

NOW THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. CLIENT IDENTIFICATION

2. ACCIDENT DETAILS

Date of Accident: Time: Location:

3. MEDICAL TREATMENT

4. INSURANCE & VEHICLE INFORMATION

5. SCOPE OF AUTHORIZATION AND LIMITED RETAINER

Attorney is authorized to investigate the accident, obtain medical, employment and vehicle records, communicate with insurers and adverse parties, and to pursue settlement or litigation on Client's behalf for damages arising from the incident described above. This authorization is limited to matters arising from the incident and does not extend to unrelated legal matters unless expressly agreed in writing.

Contingency Fee: Client agrees that Attorney's fee shall be a contingency of of gross recovery, subject to a separate written fee agreement. Client acknowledges that taxes, liens, and case-related costs will be deducted from recovery prior to distribution to Client unless otherwise provided in a fee agreement.

Costs and Advances: Client authorizes Attorney to advance reasonable costs and expenses (court costs, investigator fees, service fees, medical record fees, expert fees). Advances are to be reimbursed from recovery. Client understands that if no recovery is obtained, Client may remain responsible for court-ordered costs and unpaid treatment balances as required by applicable law.

6. AUTHORIZATION TO RELEASE RECORDS; LIENS

Client authorizes Attorney to request and receive medical, vocational, employment, insurance, and billing records related to the incident. Client authorizes providers and insurers to release such information to Attorney. Client understands Attorney may assert a charging lien or similar statutory lien for attorney fees and costs against any settlement or judgment proceeds to the extent permitted by law.

7. CLIENT OBLIGATIONS

Client shall cooperate fully with Attorney, provide truthful information, attend medical and legal appointments, and notify Attorney of any contact with insurers, adverse parties, or medical providers. Client shall not sign releases, settlement documents, or give recorded statements without prior consultation with Attorney.

8. LIMITATIONS, WITHDRAWAL, AND NO GUARANTEE

Attorney may withdraw for good cause, including failure to cooperate, conflict of interest, or nonpayment of agreed advances. Nothing in this form guarantees a particular outcome, settlement amount, or fee. Attorney will exercise professional judgment in pursuing claims but cannot warrant results.

9. NOTICES

Any notice required or permitted under this Intake Form shall be in writing and delivered to the addresses provided in Section 1 above or to other addresses subsequently provided in writing.

10. GOVERNING LAW

This Intake Form shall be governed by, and construed in accordance with, the laws of the state in which Attorney maintains principal offices, without regard to conflict of law principles.

11. ENTIRE AGREEMENT

This document, together with any separate written retainer or fee agreement executed by the parties, constitutes the entire agreement between Client and Attorney concerning the attorney-client relationship for the incident described herein, and supersedes all prior understandings, whether written or oral.

12. SEVERABILITY

If any provision of this Intake Form is held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect.

13. PRIVACY ACKNOWLEDGMENT

Client acknowledges receipt of Attorney's privacy practices summary and consents to Attorney's use of Client's personal health information and other records as necessary to represent Client in connection with the incident.

Sign Now