Workers Compensation Retainer Agreement

WORKERS' COMPENSATION RETAINER AGREEMENT

Parties and Engagement

Client Name:

Law Firm / Attorney Name:

Employment and Injury Details

Employer Name:

Job Title:    Department:

Reporting Manager:

Date of Hire:    Date of Injury/Exposure:

Scope of Representation and Fees

The Client retains the Firm to represent Client in all workers' compensation matters arising from the incident described above, including administrative claims, hearings, appeals, settlement negotiations, and related lien resolutions. The Firm will not represent Client in unrelated matters except by separate written agreement.

Contingency Fee: The compensation for legal services shall be a contingency fee equal to of the gross recovery obtained on behalf of Client by settlement, award, or judgment, unless otherwise required or limited by applicable workers' compensation law. The fee is calculated before deduction of costs and expenses.

Costs and Expenses: Client agrees to reimburse the Firm for all reasonable costs and expenses advanced by the Firm on Client's behalf, including but not limited to: filing fees, expert fees, medical record retrieval, deposition costs, transcript fees, courier and reproduction expenses. If advanced costs are not repaid from recovery, Client remains responsible for such amounts.

Initial Retainer for Costs (if any): — This amount, if collected, will be held in the Firm's trust account and applied to costs and expenses.

Authority, Settlement, and Liens

Client authorizes the Firm to negotiate and enter into settlements on Client's behalf subject to Client's final approval. The Firm will consult with Client regarding settlement terms; however, the Firm may take necessary procedural steps to protect Client's rights when immediate action is required.

Liens and Subrogation: Client acknowledges that third-party medical providers, insurance carriers, Medicare, Medi-Cal, health plans, and other entities may assert liens or claims against any recovery. Client authorizes the Firm to resolve, compromise, or litigate such liens as necessary, and Client will cooperate in executing documents to effectuate lien resolution.

Medical Records, Wage and Employment Authorization

Client expressly authorizes the Firm to obtain and review all medical records, billing records, treatment records, employment and wage records, claims files, and other documents relevant to the representation from any healthcare provider, employer, insurer, government agency, or third party. This authorization includes past, present, and future records related to the injury and condition.

Client Obligations and Cooperation

Client agrees to cooperate fully with the Firm, provide truthful information, attend appointments and hearings, execute required documents, and promptly authorize the release of records. Client will notify the Firm of any change of address, telephone number, employer, benefits, or other material changes affecting the claim.

Employment History (Relevant to Claim)

Education

Professional References

Legal Disclosures

At-Will Employment Acknowledgment: Client acknowledges that any employment relationship with current or future employers is separate from this agreement and, unless otherwise agreed in writing, remains at-will.

Equal Opportunity Statement: The Firm does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other protected category in providing legal representation.

Conflicts, Withdrawal, and Termination

The Firm represents it has conducted a conflicts check and is not aware of a present conflict. If a conflict arises, the Firm will disclose it and, if necessary, withdraw. The Firm may withdraw for good cause, including Client's failure to cooperate, false statements, or refusal to follow counsel's advice. Client may terminate this agreement in writing at any time; however termination does not relieve Client of obligations for fees and costs as permitted by law.

Governing Law and Dispute Resolution

This agreement shall be governed by the laws applicable to workers' compensation matters in the jurisdiction where the claim is filed. Any dispute concerning the interpretation or enforcement of this agreement, not resolved by mutual written agreement, shall be submitted to binding arbitration or adjudicated in the tribunal appropriate for workers' compensation disputes, as permitted by law.

Applicant Certification and Authorizations

I certify that the information provided in this agreement and supporting forms is true and complete to the best of my knowledge. I authorize the Firm to communicate with my employer, insurer, healthcare providers, and third parties as necessary to pursue my claim. I understand that false statements or omissions may be grounds for termination of representation and may be reported to appropriate authorities.

Authorization to Contact Previous Employers and Conduct Background Checks: I authorize the Firm to contact previous employers and to obtain background and wage records relevant to my claim.

Notice Regarding Statute of Limitations

Client acknowledges that strict time limits apply to workers' compensation claims. Client agrees to promptly provide all information and documents necessary to preserve Client's legal rights and to cooperate with the Firm in timely filing required claims.

Miscellaneous

Electronic Communications: Client consents to receiving communications by telephone, text message, and email regarding matters of this representation. Client must promptly notify the Firm of any change in contact information.

Entire Agreement: This document, together with any signed fee addenda, constitutes the entire agreement between the parties regarding representation for the referenced workers' compensation matter and supersedes prior agreements, whether oral or written.

Acknowledgment

By signing below, Client acknowledges that Client has read, understands, and agrees to the terms of this Workers' Compensation Retainer Agreement.

Sign Now