Legal Representation Agreement

I, ____________________________, hereinafter referred to as “Client”, retain the services of L. Clayton Burgess, A Professional Law Corporation, hereinafter referred to as “Counsel”, to represent me in the prosecution of my claim arising out of _______________________________ which occurred on or about___________________________ , in _____________________, Louisiana, (hereinafter referred to as “Matter”).

Attorney Fees

If Counsel is successful in recovering damages, Counsel will receive a percentage of the gross amount, which is obtained for you. The percentage will vary with the stage at which recovery is made. If recovery is made:

a. before filing of a lawsuit, the fee is 33 1/3% of any settlement and the costs and expenses of pursuing. the claim as described below.

b. after filing of a lawsuit, the fee is 40% of any settlement or judgment and the costs and expenses of pursuing the claim as described below.

c. For property damage, in conjunction with a personal injury case, no fee will be charged on the property damage recovery.

Attorney fees are computed on the total amount of the settlement, award, verdict or judgment before deducting costs and expenses, financial assistance, or any other disbursements. Further, if there is a structured settlement,

the fees shall be calculated on the present value or cost of the settlement. In the event that the amount of attorney fees are limited by statute, the fees charged will not exceed those limitations.

I assign, transfer, and deliver to Counsel an undivided interest in the subject matter of my claim and/or in any suit or suits filed thereon by said Attorneys, said interest amounting to 33 1/3% prior to the filing of suit and 40% after the filing of suit or commencement of arbitration. My intent is to vest this firm with an interest in the subject matter of my claim and any suit or suits filed hereon by this firm as permitted by LSA – R.S. 37:218 and afford this firm all of the rights and protection granted by state statute.

In the event that outside counsel or experts are retained to resolve any claims for reimbursement or set aside made by Medicare and Medicaid, I understand that the fees and costs of outside counsel or experts must be paid by me in addition to the fees noted above.

In the event of recovery under the Workmen’s Compensation Laws of Louisiana, the fee shall be 20% of all amounts collected or procured whether or not formal litigation has been initiated for and on behalf of the said client, plus any award for attorney’s fees under the provisions of R.S. 22:648, R.S. 23:1201.2 or any statute of Louisiana and any and all attorney’s fees awarded under the provisions of the Longshore and Harbor Workers Compensation Act. The above referenced 20% fee includes any amount placed into a Medicaid/Medicare set aside or any other third party managed or self-administered fund for the purposes of future medical expenses.

In the event of recovery under the Federal Tort Claims Act, the fee shall be 25% for any judgment rendered pursuant to 28 U.S.C. 1346(b) or any settlement made pursuant to section 28 U.S.C. 2677. In the event of an award, compromise, or settlement made pursuant to section 28 U.S.C.2672 the fee shall be 20%.

Costs Of Pursuing Your Claim

Counsel will, as its discretion, advance costs and expenses for my claim. I consent to and authorize Counsel to retain the services of any experts, doctors, investigators, etc. to work on my case and to incur expenses, which it believes, are reasonably incurred to prosecute my case.

What Are Costs And Expenses?

Costs and expenses include, but are not necessarily limited to, filing fees; court costs; medical expenses; witness fees; deposition costs; transcript costs; expert fees; expenses of investigation; fees for production of digital graphic, photographic or electronic evidence; computer forensics; charges for serving and filing papers; mileage and travel fees; copying charges; long distance telephone expenses; postage charges; overnight delivery Form 002-B-LA-PI – Rev. 09/2016 charges; outside courier or messenger services; notarial fees; recording and certifying documents; computer legal research; client’s promissory notes representing loans for living expenses; guarantees of same; and any other case specific expenses directly related to my case. I authorize the hiring of other persons and entities including, but not limited to, physicians; nurses; therapists; medical records transcriptionists; court reporters; translators; accountants; expert witnesses; and other attorneys; and authorize Counsel, in its discretion, to direct such other persons and companies to render statements for services rendered and expenses advanced either directly to Client or Counsel, in which later event Client agrees to promptly reimburse Counsel for the full amount of such statements. I further authorize Counsel to conduct a third party claim search for insurance limits.

I have been informed of, and I also consent to, paying the actual invoiced costs for the following expenses: computer legal research charges; copying charges; case related medical expenses; and any other case specific expenses directly related to my case.

The costs and expenses noted above will be paid out of any settlement or judgment obtained on my behalf. The client is only responsible for any costs and expenses incurred by Counsel if there is a recovery in the case. All of the costs, expenses, and financial assistance shall be recoverable by said attorneys in addition to the attorney fees stated above. All of the costs and expenses identified above are to be deducted from any settlement or judgment after the contingent attorney fees is deducted from the gross recovery. Any court costs, expenses, and financial assistance, as well as the attorney fees earned by our office, shall be subject to a lien upon any amount recovered on your claim.

I agree that if any refunds are received on my behalf and/or any liens, medical expenses, etc. or reduced by any amount and L. Clayton Burgess, A P.L.C. reduced its attorney’s fees or expenses by any means the refund or the reduction amount would go to L. Clayton Burgess, A P.L.C. and I would only receive funds from same if the refund or reduction is more than the original attorney’s fee and expenses.

In addition, I hereby authorize Counsel at its discretion, to guarantee payment of my outstanding medical bills and other expenses out of the net proceeds of any settlement or judgment. All medical bills not paid out of the settlement remain my responsibility. I further direct and hereby authorize Counsel to release any and all information necessary to secure funding for litigation, medical or other related expenses.

I understand that Medicare, Medicaid or private health insurance plans may require all parties involved in this matter to settle a healthcare provider’s separate claim for reimbursement/lien for past and future payments prior to distributing any verdict or settlement proceeds. I authorize hiring separate experts/case workers who assist with resolving any healthcare provider’s reimbursement claims or liens for past and/or future injury-related medical care or Medicare set a sides. The expense of any such service shall be treated as a case expense and deducted from our net recovery and shall not be paid out of the law firm’s contingent fee in this matter.

Outside Counsel

I have no objection, agree to, and hereby authorize Counsel to associate attorneys who are not members of the firm to handle my case if Counsel deems this necessary. However, if this happens, the total amount of attorney’s fees which I have agreed to pay will not increase and the attorneys will divide the attorney’s fees and will jointly assume responsibility for the case. I also understand that my case may be assigned to an associate attorney or contract attorney employed by Counsel, but not necessarily L. Clayton Burgess.

Settlement Of Your Claim

Counsel and Client agree that neither may, without the consent of the other, settle, compromise, release, discontinue, dismiss or otherwise dispose of any suit or claim arising out of the matter referred to above. You understand that, from the proceeds, if any, coming into our possession by way of settlement of judgment, you authorize counsel to first deduct our attorney’s fees, and then all court costs, litigation expenses, and financial assistance advanced that have not been reimbursed, as well as outstanding expenses, liens and medical bills.

A written accounting will be provided to you listing incurred fees, court costs, litigation expenses, and financial assistance, and all known outstanding liens, bills and expenses. I understand my original file may be destroyed upon resolution of my claim or termination of representation subject to this agreement and that a copy of my file may be stored electronically subject to available storage space.

Other Persons Who May Have An Interest In The Case

I hereby bind my heirs, executors and legal representatives by this agreement. I certify that I had not filed a bankruptcy petition as of this date that the cause of action arose and I have not done so to date. If I do file a bankruptcy petition, I will immediately notify Counsel of this development.

I agree to waive my Attorney-Client and/or Doctor-Patient privileges to the extent that my attorneys believe that it is necessary to disclose Form 002-B-LA-PI – Rev. 09/2016 information about me or that I have given to them to other persons in order to prosecute my case, arrange for medical treatment for me, settle my case, or as allowed by law or regulation.

Obligations Of The Client

I hereby acknowledge that by entering into this agreement for representation I have certain obligations to Counsel in order for them to be able to effectively and efficiently prosecute my claim.

I understand that my obligations include, but are not limited to:

• a) to update Counsel of any changes to my residence, mailing address, phone number or other contact information;
• b) to be open, honest and candid to Counsel concerning the matter for which representation has been undertaken and other items which may Counsel may inquire about;
• c) to promptly provide to Counsel all medical bills, liens or notices received concerning the matter for which representation has been undertaken;
• d) to promptly notify Counsel of any child support obligations, bankruptcy, criminal matters or any other items which may impact the prosecution or resolution of the claim for which representation has been undertaken
• e) to avoid making unreasonable and inappropriate demands of staff, including rude, abusive, disruptive behavior and excessive request. Failure to meet these obligations may result in our discharge from representation of you in this matter.

Withdrawal By Either Attorney Or Client

Either you or Counsel can withdraw from your case by giving reasonable written notice to the other. Any withdrawal by Counsel shall be consistent with the Louisiana Rules of Professional Conduct. In the event that you dismiss Counsel or Counsel withdraws, you hereby give Counsel a lien on your future recovery, if any, to secure payment of our costs and attorney fees incurred up until then. In the event that a settlement offer was obtained prior to withdrawal, Counsel’s attorney fee shall be the agreed percentage of the last settlement offer obtained by Counsel prior to dismissal or withdrawal.

No Assurances on Outcome Counsel agrees to use its best efforts in representing Client in this matter; however, Client acknowledges that Counsel has given no assurances regarding the outcome of this matter.

Arbitration of Attorney/Client Disputes. In the event of a dispute between you and Counsel and/or any of its employees regarding the interpretation of the terms herein, including but not limited to the management of your case, or any aspect of the attorney-client relationship, including claims of malpractice and fee disputes, you, and Counsel agree that any such dispute shall be resolved by binding arbitration pursuant to LSA-R.S. 9:4201, et seq. (Others whose interest are involved may join as a party in the arbitration so that the entire matter may be resolved at one time.) The parties agree by signing the Retainer Agreement to submit all such disputes to arbitration and nay such award made will be as final as a court judgment, without the right to appeal. However you always have the right to make a disciplinary complaint to the appropriate authorities.

Please be advised that by your agreement to arbitrate any and all future claims and/or disputes against us, you waive your right to a jury trial and right to broad discovery under state or federal law on those matters subject to

arbitration. In addition, arbitration may involve substantial up front costs compared to litigation. Further, you are advised that you have a right to independent representation to advise you before you sign this agreement. In the event of a dispute you must file a demand for arbitration with Mediation Arbitration Professional Systems, Inc. (“MAPS”), which arbitration shall be conducted according to the Rules of Mediation Arbitration Professional Systems, Inc. and by a single arbitrator.

Client Has Read This Contract

I authorize Counsel to handle my claim for the loss, which occurred, on or about the date stated in the first paragraph of this agreement. I acknowledge that I have read and understand this Agreement. I agree to the terms of this contract and further agree that it constitutes the entire agreement between us. The provisions of this contract are severable. If one part is determined to be invalid, the rest of the contract remains in effect. This contract shall be interpreted according to the laws of the State of Louisiana. There are no other agreements, oral or written.

Date:

Client:

Date:

On behalf of L. Clayton Burgess, A P.L.C.