PERSONAL INJURY QUESTIONAIRE AND CONTRACT FOR ATTORNEY SERVICES

 INSTRUCTIONS
  • Download, fill out, and print the questionare and attorney fee agreement below.
  • Attach relevant documents.
  • Fax or mail the questionare, agreement, and other documents to our office.
  • If you don't have an account with us, send us a check, give us your credit card number below, or call us with your credit card number after you have sent us the documents.
  • After we have received the documents and your payment, we will take it from there and will call you if we need anything more from you.
 
 If you have questions or would like us to fax or mail you a questionare, give us a call at (562) 596-8177, send us a fax at (562) 596-0298, E-mail us at KinseyE@ix.netcom.com.
 PERSONAL INJURY QUESTIONARE
 ATTORNEY FEE AGREEMENTS
 PAYMENT OPTIONS

PERSONAL INJURY QUESTIONIARE

SECTION 1
CLIENT INFORMATION

 NAME & ADDRESS
 NAME/ADDRESS:
 _____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
 COUNTY:  _____________________________________________
 HOME PHONE:  (_____) _____ - __________
 BUSINESS PHONE:  (_____) _____ - __________
 FAX:  (_____) _____ - __________
 E-MAIL:  ________________________
   

 EMPLOYMENT
 EMPLOYER NAME & ADDRESS:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
 HOW LONG WITH THIS EMPLOYER?  _____________________________________________

 

 GENERAL INFORMATION
 BIRTHDAY:  _____________________________________________
 SOCIAL SECURITY #:  _____________________________________________
 DRIVER'S LIC. #:  _____________________________________________
 LENGTH RESIDENCE IN CA:  _____________________________________________
 LENGTH RESIDENCE IN COUNTY:  _____________________________________________

SECTION 2
INFORMATION ABOUT YOUR SPOUSE

 SPOUSE NAME & ADDRESS
 NAME/ADDRESS:
 _____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
 COUNTY:  _____________________________________________
 HOME PHONE:  (_____) _____ - __________
 BUSINESS PHONE:  (_____) _____ - __________
 FAX:  (_____) _____ - __________
 E-MAIL:  ________________________
   

 SPOUSE EMPLOYMENT
 EMPLOYER NAME & ADDRESS:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
 HOW LONG WITH THIS EMPLOYER?  _____________________________________________

 

 SPOUSE - GENERAL INFORMATION
 BIRTHDAY:  _____________________________________________
 SOCIAL SECURITY #:  _____________________________________________
 DRIVER'S LIC. #:  _____________________________________________
 LENGTH RESIDENCE IN CA:  _____________________________________________
 LENGTH RESIDENCE IN COUNTY:  _____________________________________________

SECTION 3
MARRIAGE & SEPARATION
 
MARRIAGE
 DATE OF MARRIAGE:  _____________________________________________
 PLACE OF MARRIAGE:  _____________________________________________
 
SEPARATION
 DATE OF SEPARATION:  _____________________________________________
 DATE OF SEPARATION:  _____________________________________________

SECTION 4
MINOR CHILDREN
 
CHILDREN OF THIS MARRIAGE

FULL LEGAL NAME

 BIRTHDATE

 AGE
 1. ______________________________________________
Living With Whom? ___________________________
Residence Address: ___________________________
____________  ______ 
2. ______________________________________________
Living With Whom? ___________________________
Residence Address: ___________________________
 ____________  ______
3. ______________________________________________
Living With Whom? ___________________________
Residence Address: ___________________________
 ____________  ______
 4. ______________________________________________
Living With Whom? ___________________________
Residence Address: ___________________________
____________   ______
 
CHILDREN NOT OF THIS MARRIAGE
FULL LEGAL NAME  BIRTHDATE  AGE
 1. ______________________________________________
Living With Whom? ___________________________
Residence Address: ___________________________
 ____________   ______
 2. ______________________________________________
Living With Whom? ___________________________
Residence Address: ___________________________
 ____________   ______
 3. ______________________________________________
Living With Whom? ___________________________
Residence Address: ___________________________
 ____________   ______

SECTION 5
INCOME & EXPENSE INFORMATION
*
GENERAL INFORMATION
*
 1. Are you receiving or have you applied for or do you intend to apply for welfare or AFDC?
____ Receiving ____ Applied For ____ Intend To Apply For ____ No
 2. What is your date of bitth (month/day/year) . . . . . . . . . . . . . . . . . . . . . ___________
 3. What is your occupation? _______________________________________________
 4. Highest year of education completed: _____________________________________
 5. Are you currently employed? ____ Yes ____ No
 a. If yes: (1) Where do you work? (name & address) _____________________
    ____________________________________________________
    (2) When did you start work? (month/year) ____________________
b. If no: (1) When did you last work (month/year)? _______________________
    (2) What were your gross monthly earnings? $_________________
 6. What is the total number of minor children you are legally obligated to support? ____
*
INCOME INFORMATION
*
 1. Total gross salary or wages, including commissions, bonuses, and
overtime paid during the last 12 months: . . . . . . . . . . . . . . . . . . . . $_____________
 2. All other money received during the last 12 months except welfare
AFDC, SSI, spousal support from this marriage, or any child
support. (Include pensions, social security, disability, unemployment,
military basic allowance for quarters (BAQ), spousal support from a
different marriage, dividends, interest or royalty, trust income, and
annuities. Include income from a business, rental properties, and
reimbursement of job-related expenses.)
** Prepare and attach a schedule showing gross receipts less cash
expenses for each business or rental property . . . . . . . . . . . . . . . $____________
 3. Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________
DIVIDE THE RESULT IN LINE 3 ABOVE, DIVIDE IT BY 12 TO GET A MONTHLY AVERAGE FOR THE LAST 12 MONTHS, AND INSERT IN LINE 4a BELOW
 
ENTER YOUR GROSS INCOME FOR LAST MONTH INTO LINE 4b BELOW

     
 Average monthly
last 12 months

 Last month
 4. Gross income   4a $__________   4b $__________
     
 5. State income tax   5a $__________   5b $__________
 6. Federal Income tax   6a $__________   6b $__________
 7. Social Security and Hospital Tax ("FICA"
and "MEDI") or self-employment tax, or the amount used to secure retirement or disability benefits
  7a $__________   7b $__________
 8. Health insurance for you and any children
you are required to support
  8a $__________   8b $__________
 9. State disability insurance   9a $__________   9b $__________
10. Mandatory union dues 10a $__________ 10b $__________
11. Mandatory retirement and pension fund
contributions (Do not include any deduction claimed in item 7)
11a $__________  11b $__________
12. Court-ordered child support, court
ordered spousal support, and voluntarily paid child support in an amount not more than the guideline amount actually being paid for a relationship OTHER than that involved in this proceeding.
 12a $__________  12b $__________
13. Necessary job-related expenses (attach
explanation)
 13a $__________  13b $__________
14. Hardship deduction (Line 4d from Child
Support Information below)
 14a $__________  14b $__________
15. Add lines 5 through 14
TOTAL MONTHLY DEDUCTIONS:
 15a $__________  15b $__________
16. Subtract line 15 from line 4
NET MONTHLY DISPOSABLE INCOME:
 16a $__________  16b $__________
17. AFDC, welfare, spousal support from this marriage, and child
support from other relationships received each month.
 17 $__________
18. Cash and check accounts  18 $__________
19. Savings, credit union, certificates of deposit, and money
market accounts.
 19 $__________
20. Stocks, bonds, and other liquid assets:  20 $__________
21. All other property, real or personal (attach a list with values)  21 $__________
 ATTACH A COPY OF YOUR THREE MOST RECENT PAY STUBS.
 *
EXPENSE INFORMATION
*

 1. PERSONS IN YOUR HOME:
   Name Age Relationship Gross Monthly Income
 a. List all persons living in your home whose expenses are included below (continue on attachment)  1. _____________________  ____  ___________ $_________
 2. _____________________  ____  ___________ $_________
 3. _____________________  ____  ___________ $_________
 4. _____________________  ____  ___________ $_________

 ===========================================================
b. List all other persons whose expenses are not included below living in your home  1. _____________________  ____   ___________ $_________
 2. _____________________  ____   ___________ $_________
 3. _____________________  ____   ___________ $_________

 ===========================================================

2. MONTHLY EXPENSES
 a. Residence payments    
 (1) ____ Rent or ____ Mortgage
   $_________
 (2) If mortgage, include:
    
 Average principle
  $_________  
 Average interest
  $_________  
 Impound for real proiperty taxes
  $_________  
 Impound for homeowner's
insurance
 $_________  
 (3) Real property taxes (if not included
in item 2)
  $_________
 (4) Homeowner's or renter's insurance
(if not included in item 2)
  $_________
 (5) Maintenance
   $_________ 
 b. Unreimbursed medical and dental expenses   $_________ 
 c. Child care   $_________ 
 d. Children's education   $_________ 
 e. Food at home and household supplies   $_________
 f. Food eating out   $_________
 g. Utilities   $_________
 h. Telephone   $_________
 i. Laundry and cleaning   $_________
 j. Clothing   $_________ 
 k. Insurance (Life, accident, etc. Do not include
auto, home, or health insurance)
  $_________ 
 l. Education (specify)   $_________ 
 m. Entertainment   $_________ 
 n. Transportation and auto expenses
(Insurance, gas, oil, and repair)
  $_________
 o. Installment payments (insert total and
itemize in #3 below)
  $_________
 p. Other (specify)   $_________
 q. TOTAL EXPENSES (a-p)
(do not included amounts in a(2)
  $_________ 
         
 3. ITEMIZATION OF INSTALLMENT PAYMENTS OR OTHER DEBTS
(Attach a continuation sheet if necessary)
 Creditor's Name Payment For Monthly Payment Balance Date Last Payment Made
 ____________________  _______________  $_________  $_________  ________
 ____________________ _______________   $_________  $_________  ________ 
 ____________________ _______________   $_________  $_________   ________
 ____________________ _______________   $_________  $_________   ________
   

 4. ATTORNEY FEES AND COSTS OF SUIT
   
 a. To date I have paid my attorney for fees and costs:  $_________
 The source of this money was: ____________________________________
 b. I owe to date the following fees and costs over the amount paid:  $_________
 c. My arrangement for attorney fees and costs is:  
 ______________________________________________________________
* 
CHILD SUPPORT INFORMATION
(THIS SECTION MUST BE COMPLETED ONLY IF CHILD SUPPORT IS AN ISSUE
*
1. Health insurance for my children ____ is ____ is not available through my employer
 a. Monthly cost paid by me or on my behalf for children
only (Do not include the amount paid or payable by your employer:
 $_________
 b. Name of carrier: _________________
 c. Address of carrier: ________________
     
 d. Policy or group policy number: ________
    
     
 2. Approximate percentage of time each parent has primary physical responsibility
for the children:
Mother ____% Father ____%
     
 3. The court is requested to order the following as additional child support:
 ____ Child care costs related to employment or to reasonably necessary
education or training for employment skills.
(1) Monthly amount currently paid by mother: $_______
(2) Monthly amount currently paid by father: $_______
____ Uninsured health care costs for the children (For each cost state the
purpose for which the costs was incurred and the estimated monthly, yearly, or lump sum amount paid by each parent.
________________________
________________________
____ Educational or other special needs of the children (for each cost
state the purpose for which the cost was incurred and the estimated monthly, yearly, or lump sum amount paid by each parent.
________________________
________________________
____ Travel expense for visitation;
(1) Monthly amount currently paid by mother: $_________
(2) Monthly amount currently paid by father $_________
 4. ____ The court is requested to allow the deductions identified below,
    which are justifiable expenses that have caused an extreme financial hardship:
 Hardship Expense
 Amount paid per month
 How many months will you need to make these payments
     a. ____ Extraordinary health care expenses
      (specify and attach any supporting documents)
 $_________  _________
     b. ____ Uninsured catastrophic losses
      (specify and attach supporting documents)
 $_________  _________
     c. ____ Minimum basic living expenses of
      dependent minor children from other marriages or relationships who live with you (specify names and ages of these children)
 $_________  _________
     
 d. Total hardship deductions requested (add
lines a-c)
 $_________  

 SECTION 6
OCCUPATION
 (a) The name and address of your employer and the date you were first so employed.
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Date First Employed: ________________________________
  (b) A brief descriptions of your work.
_________________________________________________
_________________________________________________
_________________________________________________
 (c) The name and address of your superior best qualified to testify as to the nature of your employment and the manner of your performance
_________________________________________________
_________________________________________________
_________________________________________________
 (d) Your rate of pay since the time you commenced this occupation and the method of determining it ( e.g., hourly, weekly, monthly, commission, etc.)
_________________________________________________
_________________________________________________
_________________________________________________
 (e) Answer questions (a) through (d), inclusive, for any other employment you have had during the past 10 years.
_________________________________________________
_________________________________________________
_________________________________________________
 (f) Answer questions (a) and (b) for each employment your spouse has had in the last 10 years.
_________________________________________________
_________________________________________________
_________________________________________________
 (g) The records you have to show your earnings over the past 10 years.
_________________________________________________
_________________________________________________
_________________________________________________

 (h) Do you have available income tax returns for the past 10 years, showing your earnings during that time? If they are incomplete, please advise for which years you have them.

_________________________________________________
_________________________________________________
_________________________________________________

 SECTION 7
INSURANCE
 With reference to insurance, please state:
 (a) The name and local address of each insurance company with whom you carry any type of liability insurance protection (home, automobile, business, etc.), including the policy number and the effective dates, beginning and expiration, of each policy.
_________________________________________________
_________________________________________________
_________________________________________________
 (b) List all insurance policies which provide for payments of your medical expenses (such as C.P.S., Blue Cross, Kaiser Hospital, Automobile Insurance Medical Pay Provisions, Union Insurance, etc.).
_________________________________________________
_________________________________________________
_________________________________________________
 (c) With which of the foregoing companies have you made any claim for payment arising out of your present accident? Attach copies of claims if you have some.
_________________________________________________
_________________________________________________
_________________________________________________
 (d) Have you ever made any claim under any of the foregoing policies or under any other policy you may have had during your lifetime? If so, identify each claim and the policy under which it was made.
_________________________________________________
_________________________________________________
_________________________________________________
 (e) Retain a list of all payments made arising out of your present accident and, if at all possible, secure copies of all medical bills (doctors, hospital, x-rays, drugs, etc.) for which such payments were made. If you have any such records in your possession now, please describe them:
_________________________________________________
_________________________________________________
_________________________________________________
 (f) Have you had any difficulty in obtaining benefits you feel you are entitled to recover under these policies? If so, tell us the problem.
_________________________________________________
_________________________________________________
_________________________________________________

 SECTION 8
THE INCIDENT
 
 (a) Date: ______________ Time: ______________
 (b) Place:
_________________________________________________
_________________________________________________
_________________________________________________
 (c) Describe the incident in detail. What happened? What caused the parties to be injured?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 9
OTHER PARTIES
 List the names ot each party involved in the incident and, for each party, include:
1. The name, address, and telephone number of each party
2. The role of the party in the incident; and
3. The name, address, and telephone number of the attorney for the party (if any).
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 10
WITNESSES
 List the names, addresses and telephone numbers ot each witness to the incident.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 
 SECTION 11
INJURIES
 A. YOUR INJURIES: Describe the injuries you sustained as a result of the incident.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
B. INJURIES SUSTAINED BY OTHER PARTIES: Describe the injuries sustained by other parties.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 12
STATEMENTS AND REPORTS AT THE TIME OF THE INCIDENT
STATEMENTS & INCIDENT REPORTS AT TIME OF THE INCIDENT: At the time of the incident described above, did you make any statements to police, fire, emergency personal, or other investigators? If so indicate what statements were made, to whom they were made, and the location of each report of your statements:.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 13
STATEMENTS AND REPORTS TO INSURANCE COMPANIES
STATEMENTS TO INSURANCE COMPANY: Have you ever talked with, personally or by telephone, any insurance company or other claim representative relating to your accident? If so,
 (a) Did you sign a statement? (If so, and a copy was left with you, please return it with the answers, to this questionnaire). __________________
 (b) Was the statement written down by the representative, regardless of whether or not you signed it? ____________
 (c) Was more than one person present at the interview (perhaps a shorthand reporter)?

 SECTION 14
TREATMENT
TREATMENT: Briefly describe the treatment you have received from the date of the incident giving rise to your claim to this date:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 15
PHYSICIANS
PHYSICIANS: Give the name, address, and telephone number of each physician or other medical person who diagnosed or treated you for injuries resulting from the incident described above. For each such person, describe the treatment he or she provided you and the date it was provided:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 16
HOSPITALS
HOSPITALS: Give the name and address of each hospital or other medical facility in which you received treatment for injuries suffered as a result of the incident described above. For each such facility, describe the treatment you received and the date upon which it was received:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 17
MEDICATION
MEDICATION: Describe all medications you have been prescribed in connection with the injuries you suffered as a result of the incident described above:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 18
THERAPY
THERAPY: Describe the course of all therapies you have had in connection with the injuries you suffered as a result of the incident described above. Indicate how long you expect to continue your therapy.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 19
PROGNOSIS
PROGNOSIS: Describe what you be to be the probable final outcome of your therapy and treatment for the injuries you sustained as a result of the incident described above. (For example - do you expect to be completely cured or do you expect for there to be some permanent injury).
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 
 SECTION 20
OTHER ACTIONS
OTHER ACTIONS: If you have ever made any claim orally or in writing, or filed any action or proceeding for personal injury, property damage, workmen's compensation, or other type of proceeding seeking damages, state:
 (a) The date and nature of each such claim, how it arose (e.g., automobile accident, slip and fall), the name and address of any attorney who may have represented you, the name of the defendant (including the insurance company involved), and the final outcome
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
 (b) What part or parts of your body were injured as a result of the foregoing?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
 (c) What, if any, portions of your body that were injured in your present accident were injured in any way in the earlier accidents you have just described?
_________________________________________________________________
_________________________________________________________________

 SECTION 21
OTHER ILLNESSES
ILLNESSES: List all other illnesses or physical conditions for which you have ever received medical attention (excluding colds, influenza, and childhood diseases). Give the name and location of each hospital from which you received any treatment either as an in-patient or as an out-patient.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 22
OTHER INJURIES
OTHER INJURIES: List all other injuries which you have ever sustained, regardless of when or how, and give the names and addresses of all doctors and hospitals from which you received treatment for such injuries.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 23
NONINJURY ACCIDENTS
NONINJURY ACCIDENTS: List all other noninjury accidents in which you were involved. If automobile damage was involved, give the extent of the damage.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 SECTION 24
PROPERTY DAMAGE
PROPERTY DAMAGE: Describe all property damage resulting from the incident. Attach copies of the repair bills or advise us in what other way the amount of the damage or cost of replacement, if totally destroyed, can be determined.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 
 SECTION 25
EFFECTS OF THE INJURY
. INJURIES: One of the most important aspects of your injury is the effect it has had upon you
 (a) If there is pain involved, state the portion of your body which is painful, and describe the severity and frequency of the attacks of pain. It would be well if you would make a note on a calendar or diary each time the painful episode occurs.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
 (b) When you find that your injury prevents you from engaging in any activity, whether part of your work or recreational, that you could do before, note the date and the nature of the activity interfered with. If it involved housework, such as cleaning or ironing, also note the particular type of activity.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
 (c) If possible, pay all of your bills, whether medical, hospital, or drug, etc., by check. When it is necessary that you take taxicabs, secure a receipt from the driver, if possible.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
 (d) Record the date of your first return to work, the degree of work you were then able to perform, and the date you were able to resume fully your former activities. Also advise us when the doctor indicates your treatment is coming to a close.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

 

 

 

ATTORNEY FEE AGREEMENTS

Note: If you are a Plaintiff, if we take your case it will probably be on a "contingency fee" basis. If we are representing you as a defendant, your agreement with us will probably be on an hourly fee basis.
 CONTINGENCY FEE AGREEMENT (FOR PLAINTIFFS)
 HOURLY FEE AGREEMENT (FOR DEFENDANTS)

 

 ATTORNEY FEE AGREEMENT
(Contingency Fee)
 

 

THIS IS AN AGREEMENT between _______________________________,
__________________________________________________________________
hereinafter referred to as "Client," and LAW OFFICES OF EUGENE E. KINSEY, INC., hereinafter referred to as "Attorneys."
 
1. MATTER COVERED: Client retains Attorneys to represent Client in connection with a claim for damages, injury, or loss against such persons who may be liable therefor, arising out of the following accident or transaction:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
 
2. SERVICES TO BE PERFORMED BY ATTORNEYS: Attorneys agree to perform the legal services reasonably required to prosecute Client's claim to judgment in a trial court; and to prosecute or oppose any motion for new trial.
The services covered by this Agreement will terminate when all matters are concluded in the trial court. Services on appeal or other proceedings to enforce the judgment are not covered by this Agreement; if those services are necessary, we can at that time negotiate a new fee agreement.
 
3. NO GUARANTEE AS TO RESULT: Client acknowledges that Attorneys have made no guarantee as to the outcome or amounts recoverable in connection with Client's claim.
 
4. LITIGATION COSTS AND EXPENSES: Client shall be responsible for all costs and expenses incurred by Attorneys in connection with Client's claim including without limitation the following: court filing fees, process serving fees, investigators' fees, fees to experts for consultation with attorney and/or appearance at deposition or trial, jury fees, messenger and mail expenses, travel expenses.
Attorneys may advance any or all of such costs and expenses on Client's behalf, in which event, client agrees to reimburse Attorneys upon demand. such reimbursement shall be made regardless of the status or outcome of the legal action on Client's claim, or the amount recovered.

5. CONTINGENCY FEE TO ATTORNEY: Client acknowledges that he/she has been advised by Attorneys that any contingency fee is negotiable and is not set by law.
Bearing such advice in mind, Client agrees to pay to Attorneys a fee of 33.33% percent of any recovery, whether such recovery is by way of settlement, judgment or otherwise.
 
6. COSTS AND EXPENSES AS AFFECTING CONTINGENCY FEE: Costs and expenses incurred in connection with the prosecution or settlement of Client's claim shall be reimbursed before the contingency fee is computed. For example, if Client's claim is settled for $1,000, and litigation expenses total $100, the net recovery is $900, and Attorneys' contingency fee shall be based on this amount. Client's share of the recovery shall be the balance remaining after reimbursement of such costs and expenses and payment of Attorneys' contingency fee.
 
7. FORM OF RECOVERY AS AFFECTING CONTINGENCY FEE: In the event the recovery consists of periodic payments over a period of time, or any other form of property which is not cash or cash-equivalent, the contingency fee shall be based on the present cash value of the recovery and shall be payable out of the first funds or property received.
 
8. ATTORNEYS' LIEN: Client hereby grants Attorneys a lien on Client's claim and any cause of action filed thereon to secure payment to Attorneys of all sums due under this Agreement for services rendered and costs advanced.
 
9. CLIENT ACKNOWLEDGMENT: Client acknowledges having read all of the terms and conditions set forth in this Agreement and that he/she fully understands and agrees to same.
 
EXECUTED at Seal Beach, California on _________________, 19___.
 
ATTORNEYS CLIENT(S):
 
By: ___________________ ________________________

 ATTORNEY FEE AGREEMENT
(Hourly Fee Agreement)
 
_____________________________________________________________________,
hereinafter collectively referred to as "CLIENT," agrees jointly and severally to pay LAW OFFICES OF EUGENE E. KINSEY, INC., A California Corporation, hereinafter referred to as "ATTORNEYS," the sums specified below for the following services:
________________________________________________________________
________________________________________________________________
 
1. INITIAL RETAINER: ($300.00) Immediately upon execution of this Agreement, Client shall pay to Attorneys an initial retainer in the amount specified in this Paragraph. This initial retainer is a FEE FOR INITIAL CONSULTATION, ACCEPTANCE OF THE CASE OR OTHER UNDERTAKING, AND CREATION OF A NEW FILE ONLY. THE INITIAL ATTORNEY RETAINER IS NOT REFUNDABLE AND SHALL NOT BE APPLIED TO ANY HOURLY FEE.
 
2. HOURLY FEE FOR ATTORNEY TIME: ($225.00) In addition to the initial attorney retainer and additional flat fee specified below, Client promises to pay to Attorneys a fee of $225.00 per working hour for each and every hour spent by a licensed attorney working on the above-described matter including but not limited to phone time, investigation, research, drafting, travel and court time. MINIMUM BILLING: Said hourly fee shall be billed in increments of no less than .25 hours; i.e. Client shall be billed for .25 hours for each billable period of .25 hours OR PART THEREOF.
 
3. OTHER HOURLY FEES: In addition to other fees described in this Agreement, Client promises to pay to Attorneys the following sums for services rendered by office personnel other than licensed attorneys:
 Paralegals:  $75.00 per hour
 Law Clerks:  $60.00 per hour
 Secretarial:  $15.00 per hour
 Word Processing:   $15.00 per hour
 
4. HOURLY RATES SUBJECT TO CHANGE: The rates for hourly fees described above are the prevailing rates for services as of the date of execution of this Agreement and are subject to change on 30 days written notice. Should Client decline to pay any increased rate, Attorneys shall have the right to withdraw from representation of Client.
 
5. FLAT FEE: ($_______________) In addition to other fees specified in this Agreement, Client shall pay to Attorneys the flat fee specified in this Paragraph for the following services:
________________________________________________________________
________________________________________________________________
 
6. MINIMUM FEE & ADVANCE PAYMENT: Client shall pay in advance to Attorneys a MINIMUM FEE of One Thousand Dollars ($1,000) for the above-described services, exclusive of any and all costs of suit. Client understands that the said Minimum Fee is the least that Client shall pay to Attorneys for the above-described services and that the total fee to be incurred by Client may exceed the said Minimum Fee. All fees paid to Attorneys below the said Minimum Fee are NOT REFUNDABLE.

7. COSTS PAID BY CLIENT: ($_______________) In addition to attorney fees described above Client agrees to pay all costs which are reasonably necessary to perform the above-described service or to prosecute any court action which may be brought on behalf of Client in this matter or which are otherwise reasonably necessary in the representation of Client. Costs include but are not limited to court costs, process service fees, expenses of investigation, expenses of medical examination, computer database access, and the cost of obtaining and presenting evidence. Client shall immediately upon execution of this Agreement advance to Attorneys the sum described in this Paragraph for costs to be placed in a trust account for the benefit of Client. All costs which are not used ARE REFUNDABLE.
 
8. ADVANCEMENT OF ESTIMATED TRIAL FEES & COSTS UPON NOTICE OF TRIAL (LITIGATION MATTERS ONLY): Should a court action be prosecuted by Attorneys in connection with the above-described matter(s), within ten (10) days of receipt by Attorneys of notice of a trial date, Client promises to advance to Attorneys 1) all attorney fees and costs then due and unpaid and 2) all attorney fees and costs which Attorneys estimate will be incurred by client in the preparation for and prosecution of the trial. Should Client fail to advance the fees and costs described in this Paragraph when due, Attorneys, at their option, shall be permitted to withdraw from representation of Client and Client, upon the exercise of such option by Attorneys, shall sign all documents and do all things reasonably necessary to accomplish such withdrawal.
 
9. AUTHORIZATION FOR WITHDRAWAL FROM TRUST ACCOUNT: Attorneys are authorized to withdraw and disburse from Client's trust account such sums as are reasonably necessary to pay costs of suit brought on behalf of Client and which are reasonably necessary to pay Attorney fees as they are incurred.
 
10. PAYMENT OF FEES: Client promises to pay Attorneys all sums due in full on or before the fifth day after billing. Should client fail to make any payment when due, Attorneys are authorized to withdraw from Client's trust account and pay the amount of any such payment to Attorneys without prior notice to client.
 
11. CREDIT CARD AUTHORIZATION: Client authorizes Attorneys to debit any credit card to which Client is signatory including but not limited to the following a] immediately for any returned check and/or b) for any and all sums due and unpaid on the Thirtieth (30th) day after the due date thereof:
 
 CARD:  ________________________________
 HOLDER  ________________________________
 CARD NUMBER  ________________________________
 EXPIRATION DATE:  ________________________________
BILLING ADDRESS FOR THIS CARD:
 
________________________________
________________________________
________________________________
 

12. LATE SERVICE CHARGE: If any payment or portion thereof due under this Agreement is not received by Attorneys within ten (10) days after the due date thereof, Client agrees to pay Attorneys, in addition to the payment due, a late service charge of five percent (5%) of the amount of such payment due and unpaid.
 
13. LIEN (LITIGATION OR CLAIM ONLY): Client hereby grants Attorneys a lien on any and all claims or causes of action that are the subject of Attorneys' representation under this Contract. Attorneys' lien will be for any sums due and owing to Attorneys at the conclusion of Attorneys' services. The lien will attach to any recovery Client may obtain, whether by arbitration award, judgment, settlement or otherwise.
 
14. DISCLAIMER OF GUARANTEE: Nothing in this Contract and nothing in Attorneys' statements to Client will be construed as a promise or guarantee about the outcome of Client's matter. Attorneys make no such promises or guarantees. Attorneys' comments about the outcome of Client's matter are expressions of opinion only.
 
15. ATTORNEY FEES FOR COLLECTION FROM CLIENT: In case suit or action is instituted to collect any sums due under this Agreement, Client agrees to pay such additional sum over and above the amount of Client's indebtedness to Attorneys as the court may adjudge reasonable as Attorney fees incurred in such suit or action.
 
16. EFFECTIVE DATE: This agreement will not take effect and Attorneys shall have no obligation to provide legal services until Client both 1) returns to Attorneys a signed copy of this agreement and, 2) makes the entire advance payment specified in Paragraph 6 herein.
 
EXECUTED at Seal Beach, California on _________________, 19____.
 
CLIENT(S):
 
_______________________________
 
 
ATTORNEYS:
 
_______________________________

 PAYMENT OPTIONS
 CREDIT CARD
- VISA, MASTERCARD,
AMERICAN EXPRESS-
  • Bring your card to the office or;
  • Include your credit card information below;
  • Call us with the information.
CHECK,
MONEY ORDER
Mail you check or money order with your questionare and attorney fee agreement.
   

CREDIT CARD INFORMATION
 CARD TYPE:  __________________________________________
 CARD NUMBER:  __________________________________________
 EXACT NAME ON CARD:  __________________________________________
 CARD NUMBER:  __________________________________________
 EXPIRATION DATE:  __________________________________________
 BILLING ADDRESS FOR THIS CARD:
 __________________________________________
 __________________________________________
 __________________________________________
 __________________________________________