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Name *
Address *
Phone *
Date of Incident *
Date of Incident
Approximate address of incident
Legal Services Agreement *
1. Parties. I (“Client(s)”) agree to employ 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 on this form on or about the date of incident indicated on this form. . 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. Case 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 Liens and Expenses. I understand and agree that I am responsible for obtaining and paying for my medical treatment and all medical expenses, claims, and liens related to this incident are my sole responsibility to pay or satisfy from my own funds. I understand and agree that my attorney is not responsible to pay, satisfy, or safeguard funds to pay or satisfy any and all medical expenses, claims, and/or liens on any recovery related to this incident. This applies to any and all medical expenses and/or liens—whether statutory, contractual, or equitable, including statutory hospital, contractual subrogation, government subrogation (Medicare and/or Medicaid), and/or any other valid or invalid lien interests in any recovery related to this incident. I specifically direct my attorney to disburse all funds recovered related to this incident directly to me after deducting funds to satisfy my attorneys lien on proceeds, as detailed below. Subject to the foregoing and at my direction, I authorize my attorney to honor, negotiate, and satisfy, according to federal and state law, any valid medical expense, assignment, claim, and/or lien related to this incident and of which my attorney is given notice. My attorney is authorized to send letters of protection to that effect. 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. Attorneys 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. I understand and agree that my attorney’s lien on proceeds is superior to, supersedes, and shall apply before any other lien—including statutory or contractual medical and/or subrogation liens—on any proceeds of any recovery from this claim, in accordance with state and federal 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. 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 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 Selden & Company PC in accordance with this special power of attorney. 15. Consent to Potential Conflict of Interest. Client understands and agrees that if any part of attorney’s representation involves a conflict of interest, such as a substantially related matter in which Client’s interests are materially and directly adverse to the interests of another client of the attorney or the attorney’s firm; or reasonably appears to be or become adversely limited by the attorney’s or firm's responsibilities to another client or to a third person or by the attorney’s or firm's own interests, the attorney reasonably believes the representation of each client will not be materially affected and each affected or potentially affected client hereby consents to such representation after full disclosure of the existence, nature, implications, and possible adverse consequences of the common representation and the advantages involved, if any. 16. 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. 17. Mutual Agreement. This agreement is not binding or enforceable until agreed upon in writing by attorney. Attorney will notify client in writing if attorney agrees or does not agree with this agreement. If any portion of this agreement is found to be unenforceable, it will not affect the enforceability or validity of any other section. 18. Applicable Law. This agreement shall be interpreted and construed according to the laws of the State of Texas.