MVA/CMV Contract & Questionnaire - RAMJI LAW GROUP, PC
  • DOCTORLAW.COM

    (713) 888-8888
  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Date of Accident. If unsure of exact date, give an estimate*
     - -
  • Did you sustain any injuries due to this accident? if yes, please explain below
  • Have you received any medical treatment for these injuries? If yes, please provide a brief description below
  • Do you have health insurance coverage? If yes, please provide the name of your insurance company below
  • Were there any passengers in the vehicle with you at the time of accident?
  • Did the Police respond?
  • POWER OF ATTORNEY AND CONTINGENT FEE CONTRACT

    THIS CONTRACT IS SUBJECT TO ARBITRATION
  • I, ("'Client"), hereby employ Ramji Law Group, PC ("Attorney") to represent me in connection with injuries sustained as a result of an accident which occurred on or about

  • Date*
     - -
  • Attorney, is hereby appointed agent and attorney-in-fact to execute in the name of and on behalf of the Client all release, receipts, settlements, discharges, and judgments necessary to the handling of this matter, including all banking and/or financial transactions pertaining to me or my spouse, or my minor child, in reference to this case.

    • PERSONAL INJURY DAMAGES 
    • IT IS UNDERSTOOD AND AGREED that my Attorney will be compensated for their time and effort required to properly perform such legal services. The amount of the Attorney’s fee is understood to be Thirty-Three and One Third (33 1/3%) of all money collected, from any 3rd and/or 1st party claims, including personal injury protection monies (PIP), including Med Pay, including Under Insured Money, including Uninsured Money, including any recovery for loss of vehicle use and Diminished Value from any settlement prior to a lawsuit being filed, Forty Percent (40%) of all money collected after the lawsuit is filed but prior to the entry of a judgment based on a jury or non-jury verdict, or Forty Five Percent (45%) of all money collected after the entry of a judgment based on a jury or non jury verdict. 

       

    • PROPERTY DAMAGE 
    • It is the client’s responsibility to provide this office with the location of the vehicle, liability insurance information, and any other pertinent information necessary to complete the claim. Ramji Law Group, PC is not responsible for any cost incurred for the storage of client’s vehicle during the property damage claims process. Furthermore, it is the client’s responsibility to mitigate the cost of storage by getting the vehicle out of storage in a timely manner. The firm is not responsible for actions taken by the storage facility.

       

    • SETTLEMENT 
    • Attorney will notify client of the terms of any settlement offer received. Attorney will not settle client’s claim without client’s approval, except when the client has failed to keep attorney informed of client’s address, telephone number, and whereabouts and attorney is unable to contact or locate client with reasonable diligence, in which case client expressly conveys to attorney a Power of Attorney to settle client’s claim for such sums as attorney deems reasonable if in attorney’s judgment it is necessary to settle client’s claim in order to protect the interest of the client. Client shall not enter into or accept any offer of settlement after execution of this agreement without the consent and approval of attorney. In the event the client does so, client shall remain obligated to attorney, the above stated contingency fee plus cost. If funds recovered are paid by check or other negotiable instrument, attorney is authorized and may endorse client’s name thereto and deposit same into attorney’s Client Trust Account for Client’s benefit. Client understands they cannot assign any interests in this contract.

      It is further understood and agreed that if it becomes necessary for said Client to be examined by a doctor or doctors that all medical expenses of any nature will be paid by Client out of any settlement obtained. Client is responsible to give Attorney any medical bills/bills/proof of lost wages associated with this case. Any bills not given will not be paid and will become wholly Client’s responsibility. Client further agrees to reimburse Attorney for all expenses related to this case out of any settlement obtained. Any monies after attorney fees, expenses and medical bills will All go to Client. Client hereby authorizes Ramji Law Group, PC to engage the services of other attorneys in the prosecution of this claim, empowering Attorney to sell, assign, or convey all or any portion of this interest, hereinabove conveyed to them. Client agrees to receive future correspondence not related to this case from Attorney’s firm. Client hereby authorizes the use of a medical record retrieval company of Ramji Law Group, PC's choice to obtain Client's medical records. The expense for this service will be taken from the total settlement amount of Client's case. Any funding or advancements necessary to further Client's case may be secured from Hancock Whitney Bank, Inc., at the rate of 8% PA, which will be passed on to Client.

    • AFFIDAVIT OF FACT 
    • I was involved in an accident on the above date, in which I suffered personal injuries. I do not know and have never met the other party who is involved in this accident before the date of this accident. I am not acting individually or together with the party who caused this accident, or any other person, to present a false and or fraudulent claim for the purpose of securing an unwarranted recovery from any person or insurance company.

      Furthermore, any facts regarding myself or the subject accident which I have stated to my attorney are true and correct and made by me with the express understanding that the same is strictly within the scope of my attorney-client relationship. Neither Ramji Law Group, PC, nor his office, nor his staff members, nor any other person, has induced, encouraged, or enticed me in anyway, to retain Ramji Law Group, PC, or any other legal counsel.

      I understand the consequences of perjury (lying under oath), and filing a false affidavit. I hereby affirm that I am not presently committing perjury or filing a false affidavit.

    • CLIENT SIGNATURE 
    • I HEREBY ACCEPT THE ABOVE CONTRACT OF EMPLOYMENT OF ATTORNEY AND I UNDERSTAND THAT THIS CONTRACT IS SUBJECT TO ARBITRATION. UPON TERMINATION/CONCLUSION OF YOUR CASE,YOUR FILE WILL BE DESTROYED AND NOT STORED.WE ENCOURAGE YOU TO KEEP/OBTAIN COPIES IF YOU DESIRE, PRIOR TO TERMINATION/CONCLUSION

      By signing, you agree to receive text messages as updates to your case as well as text for marketing even after your case has settled.
    • Date
       / /
    • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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