Interviewing of Client Wrongful Death in an Auto Accident

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1 Client(s) we represent: # Driver Passenger Left Middle Right Van(L) Van(M) Van(R) Bonar Law Group 1 Centerpointe Dr. Suite #100 La Palma, CA Telephone: (714) Fax: (714) Interviewing of Client Wrongful Death in an Auto Accident Sign-Up Date: Date of Accident: Time: pm am / Name of Deceased: Your relation to him/her? Location of the Accident: Nature his/her your trip: City of: Client Information This information is for the living heirs, husband, or rightful family members: Name: - Age: Sex: Telephone #: Marital ( ) Status: Cell # ( ) Birthdate: S.S. #: State: Driver's License #: # people inside the car: We Represent: Our Clients Employment Information Loss of Earnings? Yes: ( ) No: ( ) Occupation: Employer: Telephone #: ( ) - ext: THE BONAR LAW GROUP 1

2 How long have you been married? Were you legally married? How many children did you have together? Spouse Information Wedding Date: See the following pages for more information about the children (page 6) Client s Insurance Information Π Your Insurance Carrier: Telephone #: ( ) Coverage: BI PD MP Rental UM UMPD CD Notes: Expiration Date: Policy #: CLAIM # f Adjuster s Name ADDRESS Telephone #:( ) FAX # I.D. / Member #: Health Insurance: If none, please leave blank. THE BONAR LAW GROUP 2

3 Deceased Injury Information This information is about the deceased: Name: - Age: Sex: Birthdate: S.S. #: Driver's License #: State: Restrictions? Health Concerns? Date of Death Deceased s Occupation: How do you think the death occurred? Is there an autopsy? Name of Employer: Telephone #: Annual Salary: Yes: ( ) No: ( ) City/Station/ Establishment: Contact #: Other Info: Did he/she have Ambulance Service? Yes: ( ) No: ( ) Emergency Treatment at: Tel. #: ( ) Patient # Other relevant information: THE BONAR LAW GROUP 3

4 Facts of the Accident The vehicle of the deceased : Mark where the deceased was seated Driver Front Pass. L M R VAN POSITIONING Where was the deceased seated at the time of the accident? Who else was present during the accident? Information About the Vehicle in which the deceased was located: Vehicle Make: Body Type: Your License Plate #: Vin #: Registered Owner: Year : 5 Is the vehicle drivable? Yes ( ) No ( ) or TOTALLED? Location of the vehicle: **Where is the vehicle located right now? *** Damage on vehicle: (Pls. describe the damage) Color : Who is the registered owner of this car? Their Telephone #: Please mark below as to where the damage on your vehicle is located. State the Damages to the Vehicles ** If you have pictures, please let us know. It is extremely helpful for us ** Damage on Your Vehicle Mark where the damage is to YOUR Vehicle. Damage on his/her vehicle Mark where the damage is on the OTHER vehicle. Your Vehicle OTHER Vehicle YOUR VEHICLE OTHER PARTY S VEHICLE ***Please turn to Page 4 to draw the scene/diagram of the accident. THE BONAR LAW GROUP 4

5 The Accident Facts # of People Injured or # of Vehicles Involved? Dead? CHP / Police Investigation: Yes ( ) No ( ) Report #: CHP / Police Telephone #: ( ) Office Name: CHP / Police Department: City of: Witness Name(s): Telephone #: ( ) Witness Name(s): Telephone #: ( ) Describe the Accident? ***Please turn to Page 4 to draw the scene/diagram of the accident Other Party s Information (Defendant) Other Driver s Name: Telephone #: ( ) Vehicle License Plate #: Registered Owner: His/Her Insurance Information: (very important) Insurance Carrier: Date of Birth: Age: s Vehicle Make: Driver s License #: The person who caused the accident Telephone #: ( ) - Adjuster s Telephone Name: #: ( ) - Policy #: Claim #: Special Notes: THE BONAR LAW GROUP 5

6 Other Possible Defendant s Information: In cases where there are multiple factors of cause, this information is needed to thoroughly cover all the parties involved. Other Driver s Name: Telephone #: ( ) Vehicle License Plate #: Registered Owner: Another person who may have caused the accident Date of Birth: Age: s Vehicle Make: Driver s License #: His/Her Insurance Information: (very important) Insurance Carrier: Adjuster s Telephone #: ( ) - Name: Policy #: Claim #: Telephone #: ( ) - Special Notes: THE BONAR LAW GROUP 6

7 (1) Dependents Children of the Deceased / Rightful Heirs Name: Telephone #: ( ) - Age: Sex: Legal Guardian Birth date: S.S. #: - - School Attending: Mother s Name: Special Notes: Grade Level: Father s Name (2) Name: Telephone #: ( ) - Age: Sex: Legal Guardian Birth date: S.S. #: - - School Attending: Mother s Name: Special Notes: Grade Level: Father s Name (3) Name: Telephone #: ( ) - Age: Sex: Legal Guardian Birth date: S.S. #: - - School Attending: Mother s Name: Special Notes: Grade Level: Father s Name THE BONAR LAW GROUP 7

8 Diagram of the Accident ** Please indicate YOUR car and the other cars involved in your accident. Remember to include the street names/road names. ** THE BONAR LAW GROUP 8

9 RETAINER AGREEMENT THIS AGREEMENT, made this (date), at by and between, hereinafter designated as CLIENT and THE BONAR LAW GROUP, hereinafter designated as ATTORNEY. Client in Consideration of professional services rendered and to be rendered by Attorney to Client, hereby retains Attorney to render professional services and to do such things necessary and proper to prosecute any and all claims of Client against any person(s) or firm(s) responsible for injuries and damages sustained by Client resulting from the accident occurring on or about the day of, 20, including but not limited to those which resulted from the negligent or wrongful acts of the defendants. F E E A G R E E M E N T Paragraph 1 Attorney is hereby authorized by the client to take any and all steps in her absolute discretion deemed necessary by Attorney regarding client s claim, including but not limited to effecting a compromise of said claim, entering into arbitration or instituting appropriate litigation proceedings. Paragraph 2 Client agrees to cooperate fully in all phases of litigation and immediately notify Attorney of any changes in address, telephone number or employment. Paragraph 3 Client acknowledges that Attorney may, in her sole and unfettered discretion, associate with other counsel / counsels, Compensations for such counsel / counsels and will be the sole responsibility of Attorney. Paragraph 4 ( a ) CONTINGENCY : Client agrees to pay Attorney for such professional services, thirty-three and one third percent ( 33 1/3 % ) of the gross recovery ( regardless of manner or form) obtained on behalf of Client, if Client s claim is settled without the necessity of filing suit ; or forty percent (40%) of the gross recovery, if suit is filed and service made on the defendant ; or if Client s claim is arbitrated. Client Receives Attorney Medical Bills 33.33% 33.33% % (Depends on medical bills) (1) UNINSURED CLIENTS: If client is determined to be uninsured during the accident, according to Prop 213. Proposition 213 limits the compensation rights clients who are not insured during the time of the accident. Clients who are uninsured will be prevented from suing for non-economic losses. A client who is injured while breaking the law may sue on the basis of the other person's negligence in causing the injury. (i.e. : medical costs and property damages). Attorney cannot guarantee any full recovery if client is uninsured. ( b ) DISBURSEMENT AFTER RECOVERY : Attorney in her discretion will advance all costs which shall be deducted from the gross recovery obtained by Attorney on behalf of Client. Any costs incurred by Attorney on behalf of Client together with any outstanding liens agreed upon between Client and Attorney, or required by Statute, shall be deducted from the gross amount of recovery. The Balance of the total amount recovered shall constitute Client s net recovery. ( c ) COSTS : Although Attorney, in her sole and unfettered discretion will advance all costs, Client agrees to reimburse Attorney for all cost expended by her, including but not limited to the following costs : postage, photography, medical record/billing fees from medical facilities & hospitals, filing service, investigation, interpreters, experts, records securement fees, photocopying, filing fees, any misc. office fees associated with client s file, deposition fees/charges, skip trace searches and cost for any trial or arbitration. It is further understood and agreed that the cost of all medical care received by Client is the responsibility of Client and that the same does not constitute costs under this agreement, nor charges against Attorney subject to any liens therefore being agreed upon between Client and Attorney Pursuant to Paragraph 4 ( b ). ADMINISTRATION FEE(s) : The Bonar Law Group will charge $ $50.00 minimum for each and every Client. Our firm s administration fees reflect the most reasonable fees for postage, photocopying, printing various materials, certification of any mail and costs that our incurs to expedite your case. No fee will be charged if no recovery is obtained on behalf of the Client. However, this does not include investigation fees by our office. ( d ) FEE RECOVERY : Attorney and Client hereby agree, subject to the provisions of Paragraph 4 ( e ), that Attorney will receive no fee for professional services rendered pursuant hereto if no recovery is obtained on behalf of Client. ( e ) ATTORNEY S LIEN : Client hereby grants to Attorney a lien on any causes of action or claims of Client arising hereunder and any sums received therefore, to the extent of Attorney s professional fees and any costs advanced by Attorney on behalf of Client. If Client discharges Attorney prior to any written settlement of Client s claim or causes of action being obtained by Attorney, Attorney s lien shall be based upon the number of hours expended by Attorney to the date of discharge times Attorney s hourly rate of TWO HUNDRED FIFTY DOLLARS ($250.00) and Paralegal for FIFTY DOLLARS ($50.00) an hour and the costs advanced to that date. If Client discharges Attorney subsequent to Attorney obtaining on behalf of Client a written offer to settle the claim or causes of action arising hereunder, Attorney shall be THE BONAR LAW GROUP 9

10 entitled to a lien against Client s causes of action or claims and on any sums received therefore by Clients to the extent of Attorney s fee per Paragraph 4( c ) based upon the written settlement offer and costs advanced by Attorney on Client s behalf. If Client discharges Attorney at any time, Attorney shall retain a copy of the file and the costs of duplicating the file shall be paid by the Client together with any cost incurred by Attorney on behalf of Client to the date of discharge. Paragraph 5 APPEALS: Client acknowledges that Attorney on behalf of Client will take no appeal without both parties consent. The professional fee for an Appeal is separate, apart from any fee discussed in this Agreement, and shall be negotiated between Client and Attorney. Paragraph 6 SETTLEMENT: Client and Attorney agree that no settlement shall be made without the consent of both parties. However, if client is nowhere to be found/contacted after due diligence, the attorney will have the power to settle the claim on the behalf of client as she deems fit and proper for the best interest of the client. If Client settles or compromises his claim or causes of action without the acknowledge or written consent of Attorney then client agrees to pay Attorney the professional fees indicated herein, as well as any costs advanced by Attorney on behalf of Client. Client hereby grants Attorney a lien against and assigns to Attorney, any and all sums so received by Client to the extent of professional fees earned by Attorney hereunder and costs advanced on behalf of Client and any reasonable cost of enforcing said lien and assignment. Paragraph 7 SPECIAL POWER OF ATTORNEY: Client hereby grants to The Bonar Law Group a special power of attorney to affix or sign for the client, the Client s name on any legal document or any document she deems beneficial to Client. Client hereby grants and authorizes THE BONAR LAW GROUP to affix his/her signature on checks received on Client s behalf to be deposited in the Client Trust Account for safe handling and keeping and for his/her ultimate disbursement. However, if client is no where to be found/contacted after due diligence, the attorney will have the power to settle the claim and affix the client s name on any legal document for the best interest of the client and on the behalf of client as she deems fit and proper for the best interest of the client, this includes payment of liens and bills. This includes any settlement offers, settlement releases, checks, Property Damage Settlements, any compromises and releases, which is beneficial to the client, and any documents that can protect the client. It is further understood and agreed that if, after the settlement, client is unavailable for any reason (move, out of state, out of the country, death, sickness, absent), THE BONAR LAW GROUP is authorized to endorse Client s name on any check, draft, or other instrument or document representing the recovery and to deposit Client s net recovery in THE BONAR LAW GROUP - Client s Trust Account be turned over to Client when Client becomes available. The Client Trust Account will protect the client s money and will always be available for the client, when he/she becomes available. Paragraph 8 WITHDRAWAL OF ATTORNEY: Attorney reserves the right to withdraw from this Agreement at any time upon written notice to Client at Client s last known address. Paragraph 9 REPRESENTATION BY ATTORNEY: Client acknowledges that any statement, made by Attorney regarding the successful conclusion of Client s claim or causes of action hereunder are expressions of opinion only and not guarantees. Paragraph 10 terms of this Agreement. RECEIPT OF RETAINER AGREEMENT: Client agrees that he / she has read and understood all the ACCEPTED AND APPROVED. Date: Client Signature(s) THE BONAR LAW GROUP 10

11 A U T H O R I Z A T I O N The undersigned hereby authorizes / authorize THE BONAR LAW GROUP or it s representatives to contact and correspond with Insurance Co. for the purpose of negotiating any and all claims arising from the accident dated on my / our behalf. This authorization will be valid, binding and effective for a period of two (2) years from the date indicated below and is effectively renewable and / or revocable only by the express written notice signed and dated by the undersigned explicitly revoking or renewing the same. The undersigned hereby authorizes / authorize THE BONAR LAW GROUP or its representatives to contact, interview, retain records and bills: - Insurance Companies (plaintiffs and defendants ) - physicians, hospitals, medical facilities, dental facilities and chiropractic offices - employers / contractors - school officials, or - police departments or the highway patrol; - medical establishments, - school administrators, - witnesses and - law enforcement official for the purpose of examining, inspecting and obtaining photocopies, including but not limited to reports, medical determinations, charts, x - rays, studies, correspondence, bills, payments, - traffic accident reports and other documents pertaining to the undersigned. A PHOTOSTATIC COPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL. The addressee is obligated under California Evidence Code Section 1159 to produce requested information upon presentation of this written authorization or Photostatic copy thereof. ACCEPTED AND APPROVED. Date: Client Signature(s) q Bonar Law Group 1 Centerpointe Dr. Suite #100 La Palma, CA Telephone: (714) Fax: (714) OFFICE USE ONLY: Client s Name (PRINT): Date of Loss: CLAIM # : THE BONAR LAW GROUP 11

12 AUTHORIZATION FOR RELEASE OF PATIENT MEDICAL AND/OR BILLING RECORDS HIPAA COMPLIANT AUTHORIZATION FORM I authorize (name of person or facility which has information) to release health information to: Name of person or facility to receive health information Specify name/title of person to receive health information, if known / Telephone # Street Address, City, State, Zip Code Please specify the health information you authorize to be released: MEDICAL RECORDS MEDICAL BILLS Type(s) of health information: Date(s) of treatment: The following information will not be released unless you specifically authorize it by marking the relevant box(es) below: I specifically authorize the release of information pertaining to drug and alcohol abuse, diagnosis or treatment (42 C.F.R and 2.35). I specifically authorize the release of HIV/AIDS test results (Health and Safety Code (g)). I specifically authorize the release of genetic testing information (Health and Safety Code (j)). The purpose of this release is for (check one or more): At the request of the patient/patient representative Other (state reason) THE BONAR LAW GROUP 12

13 NOTICE Hospitals, medical facilities and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws. YOUR RIGHTS This Authorization to release health information is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this Authorization except in the following cases: (1) to conduct research-related treatment, (2) to obtain information in connection with eligibility or enrollment in a health plan, (3) to determine an entity s obligation to pay a claim, or (4) to create health information to provide to a third party. This Authorization may be revoked at any time. The revocation must be in writing, signed by you or your patient representative, and delivered to THE BONAR LAW GROUP 1 Centerpointe Dr. Suite #100 La Palma, CA Telephone: (714) Fax Line: (714) The revocation will take effect when THE BONAR LAW GROUP receives it, except to the extent THE BONAR LAW GROUP or others have already relied on it. You are entitled to receive a copy of this Authorization. EXPIRATION OF AUTHORIZATION Unless otherwise revoked, this Authorization expires (insert applicable date or event). If no date is indicated, the Authorization will expire 12 months after the date of my signing this form. Print Name Signature (Patient, Parent, Guardian) Date Time Relationship to Patient (Parent, Guardian, Conservator, Patient Representative) Witness (only if patient unable to sign) THE BONAR LAW GROUP 13

14 NOTICE OF ARBITRATION FOR DISPUTES BETWEEN CLIENT & ATTORNEY ARISING FROM REPRESENTATION In the event of any dispute, claim, question, or disagreement (such as, for example, any claim brought by your of legal malpractice and/or legal fees and costs disagreements) arising from or relating to this agreement, the services of THE BONAR LAW GROUP or the breach thereof, the parties hereto shall use their best efforts to settle their dispute, claim, question, or disagreement. To this effect, they shall consult and negotiate with each other in good faith and recognizing their mutual interests, attempt to reach a just and equitable solution satisfactory to both parties. If they do not reach such solution within a period of 60 days, then, upon notice by either party to the other, all disputes, claims, questions, or differences from the aforementioned agreement shall be finally settled by arbitration administered by the American Arbitration Association in accordance with the provisions of its Arbitration Rules. The initial costs of the arbitration shall be borne equally by the parties, but the prevailing party shall be entitled to recover the cost of the arbitration, as well as all other costs and attorney s fees. Alternatively, the dispute may be resolved by submitting the matter to arbitration conducted by the Los Angeles County Bar Associated or a local ADR office (Los Angeles or Orange County, CA), in accordance with all applicable rules and statutes. The initial cost of the arbitration shall be borne by the party seeking arbitration before the Los Angeles County Bar Association or Orange County Bar Association; the prevailing party shall be entitled to recover the cots of the arbitration, as well as all other costs and attorney s fees. Disputes over fees may also be subject to voluntary mediation under California Bus. & Prof. Code Participation in mediation is a voluntary, consensual process, based on direct negotiations between the attorney and the client, and is an extension of the negotiated settlement process. NOTICE: BY SIGNING THIS CONTRACT YOU UNDERSTAND AND ARE AGREEING TO HAVE ANY AND ALL DISPUTES BETWEEN YOU AND THE BONAR LAW GROUP DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL FOR WHICH YOU WOULD OTHERWISE HAVE A RIGHT TO DEMAND AND OBTAIN. READ, ACCEPTED AND APPROVED. Date: SIGNATURE Client Signature(s) & Printed Name PRINTED NAME BELOW THE BONAR LAW GROUP 14

15 D E C L A R A T I O N U N D E R P E N A L T Y O F P E R J U R Y T E L L I N G T H E T R U T H I / WE, hereby declare under penalty of perjury that my / our decision to retain THE BONAR LAW GROUP was not the result of any promises, offer, monetary or otherwise, and was not the result of any solicitation made by THE BONAR LAW GROUP or any of her employees, representatives or assignees. I / WE, hereby declare penalty of perjury that I / WE was / were in fact driving or riding a motor vehicle at the time of the accident of, and I / WE in fact sustained injuries as a result of the aforementioned accident. I / WE declare under penalty of perjury that the foregoing is true and correct. ACCEPTED AND APPROVED. Date: Client Signature(s) THE BONAR LAW GROUP 15

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