Personal Injury Case

1
How Were You Injured?* This field is required.
Automobile Accident
Trip & Fall / Slip & Fall
Motorcycle Accident
Dog Bite / Animal Attack
Truck Accident
Defective Product
Pedestrian or Bicycle Accident
Other Injury or Accident
2
On What Date Or About When Did The Incident Happen?* This field is required.(On or about)
Date (mm-dd-yyyy)
Month
Day
Year
3
Where Approximately Did The Incident Happen?* This field is required.Location (At or about, i.e. street address / intersection, city, state)
Location (i.e. street address / intersection, city, state)
4
Tell Us About Your Case* This field is required.Describe Your Incident
Huge
Large
Normal
Small
Ok
Ok
5
Name of Opposing Party, At-Fault Party, and/or Defendant* This field is required.
Name of Opposing Party
6
Upload Your Police Report and/or Incident Report* If Available
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Select files to upload
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7
Upload Photos of the Scene, Property Damage, or other Evidence* If Available
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Select files to upload
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8
Were You Transported By Ambulance?* This field is required.
YESNO
9
Have You Received Medical Treatment?* This field is required.For example, surgical operations, chiropractic treatment, physical therapy, occupational therapy, or any other.
YESNO
10
List Your Injuries and Medical Treatment* This field is required.Descrbe your injuries and the medical treatment received to date.
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Large
Normal
Small
Ok
Ok
11
Upload Photos of Your Injuries* If Available
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12
Upload Your Medical Records and Bills* If Available
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13
Do You Have Health Insurance (Private or Government Insurance, i.e. Medicare, Medi-Cal)?* This field is required.
YESNO
14
Upload Your Health Insurance Card* If Available
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15
Upload Your Auto Insurance Card or Insurance Policy
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16
Your Full Legal Name* This field is required.
First Name
Last Name
17
Your Date of Birth* This field is required.
Date (mm-dd-yyyy)
Month
Day
Year
18
Your Email* This field is required.
example@example.com
19
Your Phone Number* This field is required.
Please enter a valid phone number.
20
Your Address (Street Number, Street Name, City/Town, State, Zip Code)* This field is required.
21
Upload Your Driver License* If Available
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Select files to upload
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22
YOUR CONSENT TO ATTORNEY CLIENT AGREEMENT TERMS: The Electronic Signature herein shall have the same effect as the original. By signing, you authorize The Sterling Firm (herein referred to as "Lawyer") to represent you in all legal actions for injury and loss resulting from the incident. The attorney-client relationship will not take effect until this agreement is expressly signed by Lawyer. There are no upfront fees. Lawyer may advance costs for pursuing your matter to be reimbursed out of any settlement or recovery, including litigation costs, investigation costs, expert costs and fees, and all other expenses. The contingency fees for legal services include: 33.33% of all gross amounts received by settlement or compromise prior to filing lawsuit within 90 days of the date of this agreement; 40.00% of all gross amounts received after 90 days; 45.00% of all gross amounts if lawsuit is filed; 50.00% of all gross amounts received by any settlement, verdict, judgment, award, or recovery at trial, mediation, or arbitration. Lawyer's fee is not set by law and is negotiable. You expressly agrees to the use of the trust account maintained with Pinnacle Bank, 21 Platform Way S, Suite 2300, Nashville, TN 37203. You permit Lawyer to assert a "charging lien" and/or attorney's lien on your matter if necessary. By signing, you consent for use of electronic transmission, electronic and online file storage, cloud computing, artificial intelligence, and e-mail communication. Lawyer is not responsible for security breaches to third-party services. You are informed of any actual and potential conflicts of interest and hereby waive such conflicts. You acknowledge that: Lawyer cannot guarantee any result, you received a copy of this agreement, and you have opportunity to consult with independent legal counsel. By signing, you hereby grant Lawyer a revocable Power of Attorney to act on your behalf.* This field is required.
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Your Consent:* This field is required.The information herein is being submitted for review by a Lawyer. Your Electronic Signature herein via this form submission shall have the same effect as the original. By signing this form submission, you hereby authorize Lawyer to represent you in all legal actions for injury and loss resulting from the incident. However, an Attorney-Client relationship is not formed until this Agreement is executed by the Lawyer. This Agreement is not binding and will not be deemed to take effect until expressly signed by Lawyer or its authorized agent. There are no upfront fees. Lawyer may advance the costs incurred for pursuing your matter to be reimbursed out of any settlement or recovery, including but not limited to litigation costs, investigation costs, expert costs and fees, and all other expenses. The contingency fees for legal services include: thirty-three and one-third percent (33.33%) of all gross amounts received by any settlement or compromise obtained prior to filing a lawsuit within ninety (90) days of the effective date of this agreement; forty percent (40.00%) of all gross amounts received after ninety (90) days; forty-five percent (45.00%) if a lawsuit is filed; and fifty percent (50.00 %) of all gross amounts received of any settlement, verdict, judgment, award, or recovery at trial, mediation, or arbitration hearing. LAWYER’S FEE IS NOT SET BY LAW AND IS NEGOTIABLE. By singing this form submission, you consent for use of electronic transmission, file storage, and communication, including but not limited to e-mail and cloud computing services. Lawyer is not responsible for security breaches to third-party services. You are informed of any and all actual and potential conflicts of interest and hereby waive such conflicts. YOU acknowledge that: Lawyer cannot promise or guarantee any result, this Agreement is negotiable, you have received a copy of this Agreement, and you have the opportunity to consult with independent legal counsel. By signing this form submission, you hereby grant Lawyer a revocable Power of Attorney to act on your behalf. YOUR SIGNATURE HERE:
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24
Legal Services

The information herein is being submitted for review by a Lawyer. Your Electronic Signature herein via this form submission shall have the same effect as the original. By signing this form submission, you authorize Lawyer to represent you in all legal actions for injury and loss resulting from the incident occurring on or about the date indicated against all parties. An Attorney-Client relationship is not formed until this Agreement is executed by the Lawyer. This Agreement is not binding and will not be deemed to take effect until expressly signed by Lawyer or its authorized agent.

There are no upfront fees. Lawyer may advance the costs incurred for pursuing your matter to be reimbursed out of any settlement or recovery, including but not limited to litigation costs, investigation costs, expert costs and fees, and all other expenses. The contingency fees for legal services include: thirty-three and one-third percent (33.33%) of all gross amounts received by any settlement or compromise obtained prior to filing a lawsuit within ninety (90) days of the effective date of this agreement; forty percent (40.00%) of all gross amounts received after ninety (90) days; forty-five percent (45.00%) if a lawsuit is filed; and fifty percent (50.00 %) of all gross amounts received of any settlement, verdict, judgment, award, or recovery at trial, mediation, or arbitration hearing. LAWYER’S FEE IS NOT SET BY LAW BUT IS NEGOTIABLE BETWEEN LAWYER AND CLIENT.

By singing this form submission, you consent for use of electronic transmission, file storage, and communication, including but not limited to e-mail and cloud computing services. Lawyer is not responsible for security breaches to third-party services. You are informed of any and all actual and potential conflicts of interest and hereby waive such conflicts. YOU acknowledge that: Lawyer cannot promise or guarantee any result, this Agreement is negotiable, you have received a copy of this Agreement, and you have the opportunity to consult with independent legal counsel. By signing this form submission, you hereby grant Lawyer a revocable Power of Attorney to act on your behalf.
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