Fill and Sign the Enterprise Tocsin from Indianola Mississippi on Form

** Date:_______________________Attorneys at LawPost Office Box ****, Mississippi **Gentlemen:I, the undersigned,_______________________________, do hereby employ you to represent my interest under the Workmen's Compensation Law of the State of Mississippi on account of______ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________________________________________________________________________ ____.I understand that your fee for services so rendered will be fixed by the Mississippi Workmen's Compensation Commission,or by the Circuit Court of _________________ County, Mississippi, or by the Supreme Court of the State of Mississippi, as the case may be, and that if same is fixed by the Mississippi Workmen's Compensation Commission it will not exceed twenty-five percent (25%) of the total amount of compensation awarded, medical benefits excluded therefrom, or if fixed by the Circuit Court of by the Supreme Court referred to aforesaid, that said fee will in no event exceed thirty-three and one-third percent (33 1/3%) of the total amount of compensation awarded, medical benefits excluded therefrom.I understand further that out of any sum you recover for me there will be withheld, in addition to the fee set forth above for attorney's services, actual out-of-pocket expenses paid by you to obtain doctors' reports, medical records, court reporters' services and deposition fees paid to doctors to testify regarding my claim. These amount will be withheld in addition to the fee set forth above. I further understand that, should medical benefits not be voluntarily supplied by my employer or the Workmen's Compensation insurance company, then, in that event, should you be successful in obtaining additional monies used to extinguish medical expenses or representing the value of future medical coverage for me, you will receive the same percentage in fee set forth above for the obtaining of those benefits which were not voluntarily supplied, without litigation, by the employer or its insurance company. Very truly yours, ________________________________ We accept employment on the basis stated hereinabove. ** BY:_____________________________ AUTHORIZATION FOR MEDICAL INFORMATION ___________________________________ TO WHOM IT MAY CONCERN:Dear Sir:This authorizes the physicians, hospital, and all medical attendants to furnish full and complete medical reports, and information hereby requested by the undersigned, to the law firm of **, **, Mississippi, or to any representative, attorney, or investigators from said firm and especially any and all medical reports concerning injuries received by ________________________________, as the result of an accident which occurred on the ______ day of___________ ,20_____. This authorization also includes examination of all hospital records, x-ray film, and furnishing of any information, including opinions, which will aid the said attorneys in the prosecution of the claims against the insurance carriers, and others, for injury sustained to represent me in connection with the claim, and to take all necessary steps to secure the collection there of.Your assistance will be sincerely appreciated. Sincerely yours, _______________________________________Address_______________________________________________________________________