Legal Negligence Intake Form

LEGAL NEGLIGENCE INTAKE FORM AND LIMITED ENGAGEMENT AGREEMENT

This Legal Negligence Intake Form and Limited Engagement Agreement is entered into between Client Name: (the "Client") and Law Firm Name: (the "Firm") as of Effective Date: .

RECITALS

WHEREAS, the Client asserts that the Client suffered injury, loss, or damage arising from an incident alleged to have been caused by the negligence of another party, described briefly as: ; and

WHEREAS, the Client desires to retain the Firm to investigate the facts, evaluate legal claims, and, if appropriate, pursue recovery on behalf of the Client under the terms set forth herein; and

WHEREAS, the Firm is willing to undertake a limited engagement for the Client subject to the terms and conditions in this Agreement.

NOW, THEREFORE, in consideration of the mutual promises set forth below, the parties agree as follows:

1. SCOPE OF ENGAGEMENT

1.1 The Firm will provide legal services limited to the investigation and pursuit of claims arising out of the incident described above, including factual investigation, preservation of evidence, legal research, negotiations with adverse parties and insurers, and filing suit if necessary. The Firm will not represent the Client in unrelated matters unless a separate written agreement is executed.

1.2 The Firm will keep the Client reasonably informed of material developments and will consult with the Client regarding settlement offers and major litigation decisions. The Firm will not settle any claim without prior authorization from the Client.

2. CLIENT INFORMATION

3. INCIDENT DETAILS

Date of Incident:    Time:

Estimated Lost Wages:    Property Damage Estimate:

4. WITNESSES AND EVIDENCE

5. INSURANCE AND PRIOR CLAIMS

Is there an applicable insurance policy relevant to the claim? Yes No

Has the Client previously filed a claim or lawsuit related to this incident? Yes No

6. AUTHORIZATION AND CONSENT

The Client authorizes the Firm to request and obtain medical, employment and other records reasonably necessary to evaluate and prosecute the claim. The Client also authorizes the Firm to share case information with experts, opposing counsel, insurers, and other third parties as necessary for representation.

I hereby authorize release of records as described above and acknowledge that false statements knowingly made may subject me to penalties. Initials:

7. FEES AND COSTS

7.1 The parties agree that the Firm will represent the Client on a contingency fee basis of: % of gross recovery, unless a different percentage is separately agreed in writing.

7.2 The Client understands that reasonable litigation expenses and costs (including filing fees, expert fees, deposition costs, and other necessary expenditures) will be advanced by the Firm or paid by the Client and will be reimbursed from any recovery before the Net Recovery is distributed to the Client or deducted as otherwise permitted by law.

7.3 If there is no recovery, the Client will not owe attorney's fees to the Firm for contingency fee work, but the Client may remain responsible for certain non-waived costs as described in a separate expense agreement.

8. STATUTE OF LIMITATIONS AND DUTY TO PRESERVE EVIDENCE

The Client acknowledges that time limitations (statutes of limitation) may bar claims if litigation is not commenced within certain periods. The Client agrees to cooperate in preserving evidence and to notify the Firm promptly of any additional information or developments.

Client acknowledges receipt of and understanding of this warning and has provided a truthful recounting of known dates relevant to the claim. Initials:

9. CONFLICT OF INTEREST; PRIVACY

The Firm will conduct a conflicts check. If the Firm identifies a conflict that precludes representation, the Firm will promptly inform the Client. The Firm will maintain client information in confidence except as required or permitted by law and as necessary to prosecute the Client's claims.

10. NOTICES

11. MISCELLANEOUS PROVISIONS

Governing Law: This Agreement shall be governed by and construed in accordance with the substantive laws of the state identified by the Firm's principal place of business unless otherwise agreed in writing.

Entire Agreement: This Agreement, together with any separate written fee or expense agreement signed by the parties, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior oral and written agreements.

Severability: If any provision of this Agreement is held invalid or unenforceable, the remainder of the Agreement shall remain in full force and effect and shall be construed to give effect to the parties' intentions to the fullest extent permitted by law.

Amendments and Waiver: Any amendment or waiver of any provision of this Agreement must be in writing and signed by both parties. No failure or delay in exercising any right shall operate as a waiver of that right.

Counterparts: This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

CERTIFICATION

By signing below the Client certifies under penalty of perjury that the information provided in this form is true and correct to the best of the Client's knowledge, and acknowledges receipt of a copy of this Agreement.

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