Lawyer Referral Service

ESRBA Lawyer Referral Service Enrollment Form

The Lawyer Referral Service is a program designed to assist members of the public who can afford to pay a lawyer, but do not know how to find one. All panel members of the Lawyer Referral Service must be licensed in Florida, must be members in good standing of The Florida Bar, and must maintain professional liability insurance coverage of not less than $100,000 in order to participate.
Name

First NameLast Name
Email
example@example.com
Bar Number
Firm Information / Mailing Address

Firm Name

Street Address

CityState / Province

Postal / Zip Code
Phone Number
Additional Attorney(s) (if applicable)
Are there, or have there ever been, in this state or elsewhere, any felony convictions, disbarments, suspensions, or disciplinary actions against you?
Other Language(s) Spoken?
Certifications / Designations?
Will you take any of the following special circumstances?

Weekend AppointmentJail VisitationEvening AppointmentHome VisitationOther
LRS Panel Signup

Choose the case types you would like to be referred.
Administrative / Government Law

GeneralMilitary LawSocial SecuritySocial Security (minors)SSIWorker's Compensation - FederalWorker's Compensation - StateVeterans BenefitsMedicare / MedicaidProfessional LicensingHRSEducation / School
Business Law

Anti-TrustBankruptcyCollectionsCommercial LitigationCopyrights / TrademarksBusiness ContractsPartnerships / CoporationsNon-Profit Organizations
Constitutional Law

Civil RightsBaker ActHIPPAFalse Arrest / Police Brutality
Consumer Law

CollectionsCredit / RepossessionsInsurance Policy DisputesLemon LawPersonal BankruptcyContracts / General
Criminal Law

Juvenile CaseDUIFelonyTrafficMisdemeanor
Family Law

AdoptionsCustody / Child SupportGuardianshipJuvenilePaternityName ChangeDivorce / Separation
Labor Law

Employer / Employee DisputesERISAPension LawWage / Benefit Dispute
Real Property

Construction Law / LitigationGeneral Contract / AgreementsCondo / HOALandlord / Tenant CommercialLandlord / Tenant (Representing Landlord)Landlord /Tenant (Representing Tenant)Mortgage ForeclosureReal Estate Litigation (Zoning / Boundaries / Land Use)
Tort Law

Federal Tort ClaimsLibel / SlanderLegal MalpracticeFraudNursing Home AbusePersonal Injury - PlaintiffPersonal Injury - DefenseProduct LiabilityProperty DamageMedical / Dental Malpractice
Wills/Probate/Trust Law

Elder LawGuardianship - Incapacitated AdultLiving WillProbateProbate LitigationSimple WillsTrusts / Estate PlanningPower of Attorney
Miscellaneous Law

AdmiraltyAppeals - CivilAppeals - CriminalEntertainment / Sports LawImmigration LawTaxationInternational LawEnvironmental Law
Application Cerfification
By checking the box below, I certify that I am currently competent to practice in the areas of law which I have indicated.

I agree to remit to the LRS 10% of any attorneys’ fees due me for services performed in connection with any LRS cases.

I agree to charge no more than $40 for the initial half-hour office consultation.
Check Box to Affirm*
Please upload the face declarations page of your current professional liability insurance policy.

Cancelof

Enroll in the LRS Program*

Lawyer Referral ServiceContact Us to update your areas of practice. You agree to remit to ESRBA a 10% Commission on fees from LRS cases within 30 days of receipt.

$150.00 Quantity

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

ESRBA Lawyer Referral Service Enrollment Form

LRS Panel Signup