I, _________________________, direct __________________________, to pay from the proceeds of any recovery related to or arising out of that incident occurring on _____________________ in which I was injured, such sums as may be due and owing to _______________________ for services which have been rendered or which will be rendered, up to a total amount of $_______________.

NOTICE: _________________________ is nevertheless liable for the fees due to _______________________ if no recovery is made.

It is understood that I shall retain all sums of money over the funds due ______________, which as referred to above, cannot exceed $ _____________.

Dated: _________________

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_________________________ By Attorney

______________________________________
_________________________ By Injured Party

Witness:

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Attorney Agreement for Injury Collection
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. Personal injury (“PI”) cases are very lucrative for attorneys. This document gives the edge to the injured party by limiting the attorney’s payment to a fixed sum. When shopping for a PI attorney, consider first comparing offers by the terms of their services. In other words, first negotiate the best terms (e.g., lowest percentage of recovery, and so on) then select the attorney, rather than selecting first and just accepting their contract.

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