Legal Client Authorisation Form

LEGAL CLIENT AUTHORISATION FORM

This Legal Client Authorisation Form (the "Authorization") is entered into as of Effective Date: by and between Client Name: with Address: and Authorized Representative: .

RECITALS

WHEREAS, Client has retained or intends to retain the Authorized Representative to act on Client's behalf in connection with the matter described below; and

WHEREAS, Client desires to authorize the Authorized Representative to perform certain actions and to receive certain information and documents on Client's behalf as set forth in this Authorization;

WHEREAS, the parties intend that the Authorized Representative may act within the scope of authority granted herein without further specific ratification so long as such acts are consistent with this Authorization.

NOW, THEREFORE, in consideration of the mutual covenants and promises contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. GRANT OF AUTHORITY

Client hereby authorizes the Authorized Representative to take the following actions on Client's behalf with respect to the Matter described in Section 2. The Authorized Representative's authority shall include, without limitation, the specific powers selected below and any acts reasonably incidental to those powers.

2. MATTER AND SCOPE

This Authorization pertains to the following matter:

The authority granted is limited to the Matter described above except as expressly provided in Section 1. The Authorized Representative shall not expend settlement funds, incur new obligations on behalf of Client, or make admissions of liability beyond the scope of this Authorization without prior written consent of Client.

3. DURATION, TERMINATION AND REVOCATION

This Authorization shall become effective on the Effective Date specified above and shall remain in effect until: Termination Date: unless earlier revoked in writing as provided below.

Client may revoke this Authorization at any time by delivering a written revocation to the Authorized Representative and to any third party reasonably known to possess Client's records. Revocation shall be effective upon receipt, but shall not affect any actions taken by the Authorized Representative in good faith prior to receipt of the revocation.

4. CONFIDENTIALITY AND PRIVILEGE

Client hereby authorizes the Authorized Representative to receive and review all confidential or privileged information related to the Matter, including but not limited to medical, financial, employment and legal records. Client acknowledges and agrees that disclosure to the Authorized Representative of privileged information is intended to be within the scope of the attorney-client privilege or other applicable confidentiality protections and that, where applicable, Client waives any privilege necessary to permit the Authorized Representative to carry out the powers granted herein.

5. FEES, COSTS, AND HANDLING OF FUNDS

Client remains responsible for any fees, costs, expenses, or disbursements incurred by the Authorized Representative in connection with the Matter, subject to any separate fee agreement. If settlement funds or other monies are received, the Authorized Representative is authorized to deposit such funds into a trust or designated account, to pay agreed fees and costs, and to disburse remaining funds to Client in accordance with written agreement or standard practice.

6. RECORDS AND THIRD-PARTY AUTHORIZATIONS

Client authorizes third parties to release records to the Authorized Representative upon presentation of this Authorization. The Authorized Representative may obtain and retain copies of such records and may provide copies to Client or others as necessary to the administration of the Matter.

7. INDEMNIFICATION

Client agrees to indemnify, defend and hold harmless the Authorized Representative and its agents from and against any liabilities, claims, losses, damages, costs or expenses (including reasonable attorney's fees) arising from acts taken by the Authorized Representative in good faith under this Authorization, except to the extent caused by the Authorized Representative's gross negligence or willful misconduct.

8. NOTICES

Any notice or communication required or permitted under this Authorization shall be in writing and delivered to the addresses below (or such other address as a party may designate by written notice):

9. GOVERNING LAW; VENUE

This Authorization shall be governed by and construed in accordance with the substantive laws of the State of without regard to conflicts of law principles. Any dispute arising out of or relating to this Authorization shall be resolved in state or federal courts located within the same state, and the parties submit to the personal jurisdiction of those courts.

10. ENTIRE AGREEMENT; AMENDMENT; SEVERABILITY; WAIVER; COUNTERPARTS

This Authorization constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior or contemporaneous understandings, agreements, communications and representations. This Authorization may be amended only by a written instrument signed by both parties. If any provision of this Authorization is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect. Failure by either party to enforce any provision of this Authorization shall not be deemed a waiver of future enforcement of that or any other provision. This Authorization may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

11. CERTIFICATION

By signing below, Client certifies that Client is of legal age and capacity to grant this Authorization, that the information provided in this form is true and correct to the best of Client's knowledge, and that Client understands the scope and effect of the powers granted herein.

Sign Now