Contingency Fee Agreement

Contingency Fee Agreement
Please fill in the information and click the PREVIEW button at the bottom to view the document before clicking submit.
Date*

MonthDayYear
Date
Your Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Date of Accident or Occupational Disease *

MonthDayYear
Date
Claim Number*
Your Name*

First NameLast Name
Signature*

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WSIB Settlements

First NameLast Name
Should be Empty: