Thank you for allowing us to serve you. We look forward to working with you to resolve your case. There's just a little bit of paperwork to go over before we get started. We promise it won't take too long. Please give us as much information as possible. If you don't know the answer to a question, please skip it and we'll get it from you later or call us at (512) 329-6800 with any questions.

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Name *
Current Address *
Current Address
Best Phone Number *
Best Phone Number
We need this because medical providers sometimes use it to verify your identity.
Date of Birth *
Date of Birth
Are you married?
Emergency contact phone number
Emergency contact phone number
Date of Incident *
Date of Incident
Approximate address, road, or intersection
Did the police investigate this incident?
Was anyone else injured in this collision?
Did you own the vehicle you were driving at the time of the incident?
Was your vehicle a total loss in this incident?
A vehicle is a total loss is if it will cost more to fix it than replace it.
Please use kbb.com or edmunds.com to estimate the "private party" sale price of your vehicle.
Please obtain a vehicle repair estimate from a reputable repair facility and list the total cost of repairs.
Do you have photos of
Do you have Personal Injury Protection (PIP) coverage?
Do you have uninsured/underinsured (UM/UIM) coverage?
Do you have health insurance?
Did you miss work as a result of this collision?
I have read and agree to the terms and conditions in the Legal Services Agreement below: *
Legal Services Agreement 1. Parties. I (“Client”) agree to employ Jon Selden & Company PC (“the firm”, “attorney”, or “attorneys”) in accordance with the following terms: 2. Scope. This agreement (“agreement” or “contract”) concerns the incident described above ("Brief Description of Incident" on or about the "Date of Incident"). 3. Contingent Fee. I understand this is a contingent fee contract for legal services and that if my Attorneys do not recover anything, then I will not owe anything to my Attorneys, including any expenses advanced or any attorneys fees. However, I understand and agree that any unpaid medical treatment charges are my sole responsibility. 4. Attorneys Fees. In consideration of legal services provided under this agreement, I assign and grant to my Attorneys the following percentage of all money, property or other interests recovered by client, or money saved or value obtained through offset or forgiveness of any obligation, as detailed below: 33-1/3% if settlement and collection are made before a lawsuit is filed and 40% if settlement and collection are made after a lawsuit is filed. I understand that attorneys fees are based on the total amount of cash and property recovered, including amounts eventually paid to medical providers, medical insurers, workers compensation carriers, or other creditors or lienholders. Attorneys fees are calculated on the gross recovery amount before any expenses are deducted. 5. Expenses. I agree to pay in advance or reimburse Attorneys for all usual and customary expenses they incur in connection with the claim. Client understands and agrees that any unpaid expenses and advances will be paid from the net recovery on Client’s claim, after calculation and deduction of Attorney’s fees. 6. Medical Bills and Subrogation Claims. Unless I direct otherwise, I authorize my Attorneys to honor, according to federal and state law, any valid health insurance or agency assignment or subrogation claim of which my attorney is given notice. Unless I direct otherwise, my attorneys are authorized to send letters of protection to that effect. My attorney may attempt to negotiate a reduction of the subrogation interest and the client will receive the benefit of the reduction, provided however that attorney will receive a fee for this service as outlined in Paragraph 4, above. 7. Joint Venture or Association of Additional Counsel: Client agrees that Attorneys may refer this matter to another lawyer or firm or associate additional lawyers or firms to assist in representing Client and prosecuting the Client’s cause of action. Prior to the referral or association proposed, Client will consent in writing to the terms of the arrangement. The referral or association of additional attorneys will not increase the total attorneys fees owed by Client. 8. Counterclaim. I understand that I am retaining the firm to pursue claims I have against the person or people or entity responsible for my injuries. If I am sued as a result of this collision or if a counterclaim is made against me, I will submit such claims or lawsuits to my own automobile liability insurance carrier for defense. 9. Withdrawal from Agreement. I authorize my Attorneys to withdraw from this agreement at any time upon the happening of any one or more of the following events: a. After due investigation of the facts and research of the law applicable to my claims, the Attorneys determine that further pursuit of my claims does not have a reasonable likelihood of success or that it is not feasible or proper to prosecute my claims; b. If I fail to cooperate with my attorneys in their prosecution of my claims or in any aspect of litigation or if I do not disclose all facts fully and accurately to Attorney, or if I do not keep Attorney informed of all developments relating to this matter, including any change in address or telephone number, or if I fail to respond to my attorney’s requests for information from me, or if I fail to keep all of my doctor’s appointments or physical therapy appointments, if any; c. If I fail, after adequate explanation by my attorney, to come to an agreement with my attorney regarding the reasonable value of my claim or if I, after adequate explanation by my attorney, refuse to accept a reasonable settlement offer and my attorney declines to file a lawsuit in accordance with Paragraph 11, below. If my Attorneys withdraw pursuant to paragraphs "a" above, the act of withdrawal will constitute a release of any further obligations I have to my Attorneys under this Agreement. If my Attorneys withdraw pursuant to paragraphs "b” or “c” above, then I will remain obligated to the firm for the compensation set forth in paragraphs 4 and 5, and the lien on proceeds discussed in paragraph 10 below will remain in full force and effect. 10. Lien on Proceeds: I agree that any proceeds of any recovery, whether they be by settlement, judgment, levy and execution, or otherwise, are to be used to satisfy the Attorney's fees to which the firm is entitled and all costs and expenses of litigation or claims preparation which remain unpaid. Client further agrees that consistent with applicable laws, statutes and ethical rules, the Firm shall have a lien upon all moneys, things of value and other consideration recovered in any claim it prosecutes on Client’s behalf, regardless of whether Firm is employed by Client at the time of such recovery. Client agrees that the above lien shall apply before any other lien on any proceeds of any recovery from this claim, in accordance with Texas law. 11. Nature of Litigation. I understand that this contract does not obligate my attorney to file a lawsuit in this matter. Attorneys have advised Client that the outcome of the trial of a lawsuit is impossible to predict. 12. Settlement. Attorneys will not settle Client's claims without Client's authorization, and Client will not settle the claims without Attorneys' authorization. Nothing in this agreement obligates Attorney to file a lawsuit. 13. Communication. Client agrees to not communicate any information pertaining to Client’s claims to any persons other than with Attorneys or Attorney’s staff, or to persons approved in advance by Attorney. Attorneys will maintain reasonable and necessary communication with client. 14. Special Power of Attorney. I appoint Jon Selden & Company PC and any of its duty authorized agents to be my true and lawful attorneys for and in my name, place, and stead to handle negotiations and settlement discussions including the right to sign Clients’ name on and to any insurance forms, letters, releases, checks, or other negotiable instruments made payable to the Attorney and the Client, the Attorney, or to the Client without the joinder of the Attorney, submitted to the Attorney on behalf of the client in full or partial settlement of this case. This limited power of attorney authorizes the Attorney to place any money referred to above in the Attorney’s trust account and from that trust account make distributions and payments. I ratify and confirm all actions taken by Jon Selden & Company PC in accordance with this special power of attorney. 15. Agreement Binding. Client agrees that this contract shall be binding on Client, his or her successors, heirs, executors, or assigns, and shall serve as to survive Client’s death or incompetency. 16. Applicable Law. This agreement shall be interpreted and construed according to the laws of the State of Texas and will be performed in Travis County, Texas, although any related litigation may be filed and tried in a different County or State. 17. Electronic Signature. By checking the "I have read and agree to the Legal Services Agreement below" box and clicking the "Agree" button above, I signify that I have read and agree to all the terms and conditions contained in this Agreement.