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I,  ____________________________________do hereby retain and appoint Lawrence S. Rubin, Esquire, as our attorney, to pursue any action or actions, and/or to compromise to settle any claim or claims I may have against_________________________________________ or any persons, firms or corporations because of damages suffered by me arising out of or sustained on or about as a result of an ___________________________ accident. We hire my attorney for this action only, unless otherwise agreed to in writing between us.

We agree that the attorney's fee for services rendered in my behalf in this matter shall be __(subject to negotiation - usually between 33-40% or sometimes on a graduated scale) on the gross amount received, whether obtained as a result of settlement at any time, or verdict after trial. The fee shall likewise be applicable to sums recovered for property damage, including recovery for a damaged or destroyed motor vehicle.

We agree to pay all direct costs in this matter. If my attorney advances money on my behalf, we agree to repay him immediately on his demand. My attorney has made no representations as to the value of our case at the time of the execution hereof. We understand that each case stands on its own merits, and is unrelated in value to any other of seemingly similar circumstances.

It is understood that this agreement does not include services or costs which may be involved in any appeals in this matter. All services and disbursements on appeals are to be extra, and the attorney's fee for such shall be determined by mutual agreement at the time of such appeal. Whereby authorize my attorney to do any act on my behalf in this matter, and to sign any necessary papers, drafts, and releases. If at any time my attorney determines that it would be best to withdraw his representation in this matter, he shall, upon reasonable notice to me, be permitted to do so.

We understand that it is possible one or more of my insurers, or my employer's insurers (where coverage is provided for me) may request subrogation against us after settlement for, among other things, property damage or health insurance claims. Such a claim might arise if we were paid for property damage and it is later determined that we recovered for the same again from a third party. Another claim might arise where a health insurance carrier pays my medical bills and it is determined that we recovered these from a third party. Another instance might arise if this claim is related to an on-the-job injury. This list is not all-inclusive. We agree to be responsible for, and to hold my attorney harmless against any subrogation claims made against us. My attorney has explained to me the meaning of this paragraph.

We acknowledge that my attorney's fee depends on a recovery in this case. Therefore, should we discharge my attorney prior to a recovery in this case, We agree to pay him the greater of one-third of my recovery or actual time expended at his prevailing rate. In no event shall we be obligated for this or any hourly rate if the case is brought to conclusion and no settlement or verdict is obtained. In the event we discharge my attorney, we agree to repay him any advanced costs within 30 days of the date of discharge. We have been informed that the statute of limitations in the State of Pennsylvania (other state's laws will be different) is two years from the date of the accident. It is understood that my attorney is relying on my representation of the accident date to protect my rights.

We understand that payment of medical bills to my physicians, chiropractors, nurses, therapists and other medical personnel is my responsibility. We understand that my/or attorney is not responsible for collecting PIP benefits from my insurance company unless he specifically agrees to do so in writing. We acknowledge receipt of a duplicate copy of this document. Wherever the term "me","my" or "I" is used herein, the term "us","our" or "we" may be substituted if more than one person signs this agreement. This agreement shall be valid upon acceptance or upon commencement of work by attorney.


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