Workers Comp 2023 English

Taylor Lee & Associates LLC 
6855 Jimmy Carter Boulevard Building 2100, Suite 2150 
Norcross, Georgia 30071 
Telephone: (770) 650-7200 
Fax Number: (678) 735-4512   

Client: DOB:  



Date of injury:  

Telephone: Home:  

Next of kin:  

  1. The above listed Client hereby retains Taylor Lee & Associates, LLC (the “Firm") and authorizes the Firm to perform all services and incur all costs and expenses, in the sole discretion of the Firm, deemed necessary for legal representation based on the following terms and conditions.
  2. Client retains the Firm to provide only the below listed services: 

    The Client suffered injuries as a result of a work-related accident that occurred on or about , in County, Georgia.  The Client wishes file a claim with the Georgia State Board of Worker’s Compensation against the responsible party (the “Services”).  

  3. The Firm shall begin work on the Services upon the Client agreeing to the payment terms set forth below (the “Fees”), and the Client providing all documents and information required for the Services (the “Required Documents”).
    • Client agrees to provide any and all demographic and family information.  
    • Client shall provide any documentation required for the prosecution of the case, including, affidavits, cell phone records, and photos. 
    • Client shall provide an accurate medical history, including, without limitation, a description of any prior injuries or cases with other attorneys. 
    • Client understands that the Firm will only pursue a worker’s compensation claim and will not pursue any civil claims under this Agreement.  
    • Client understands that the Firm is not obligated to pursue collection of any judgments obtained, or pursue a responsible party once all available insurance proceeds are exhausted. 
    • Client acknowledges and understands that to the extent Client refuses to provide information, or any information provided by Client is inaccurate, that the Firm is not responsible for the consequences of inaccurate information provided by Client to the Firm.
  4. The Fees for the Services outlined shall be ContingentIF THERE IS NO RECOVERY, THERE IS NO FEE.

    • The Fees for Services shall be TWENTY-FIVE PERCENT (25%) of any and all monies recovered by the Firm. This amount shall include, but is not limited to payment of income benefits and recovery of settlement. These fees are subject to approval by the State Board of Worker’s Compensation (“Committee”), and no fees of more than One hundred ($100) will be paid unless this Agreement is approved by the Board. (Rule 108(a)).
  5. If there are any fees or expenses incurred by the Firm in the performance of the Services, the Client is responsible for any fees, costs or expenses, so long as the Firm successfully performs the Services. These expenses may include, but are not limited to, costs of investigation and case development; costs of nurses, independent medical examinations (IMEs), depositions of physicians and witnesses, medical notes and narratives, witness fees, expert witnesses, court reporters, transcripts, postage, copies, lien resolution matters, filing fees, computer research costs; travel and related expenses; mediation, and trial preparation and presentation expenses.  Client agrees all costs and expenses incurred by attorneys, will be reimbursed at the time a recovery is obtained directly from the funds recovered after attorneys’ fees have been deducted.  Subject to the termination section below, IF THERE IS NO RECOVERY, CLIENT SHALL NOT BE RESPONSIBLE FOR ANY COSTS AND EXPENSES.
  6. The Firm does not and cannot guarantee any outcome related to the Services. Furthermore, if the Client fails to provide accurate criminal or immigration history, fails to obey any Court order, or violates any state or federal law during the provision of the Services which affect the outcome of the Services, the Firm cannot be held responsible for any legal or other type of consequences caused by the Client’s acts or omissions. In such event, the Firm reserves the right to modify, at its discretion, the Fees for Services or terminate this Letter of Engagement in its entirety.
  7. The Firm will inform the Client of any actual or potential conflict of interest that may arise between the Client and the Firm or any other client. If a dispute arises, the Firm will obtain written consent from the Client to continue with the Services. If the Client and/or the Firm are not aware of a conflict of interest in and such conflict arises, the Firm could be prohibited from representing the Client.
  8. Client shall inform immediately the Firm of any changes relevant to the Services, including, without limitation, any change in the Client’s address or telephone number.   Likewise, Client agrees to provide any documents or information necessary to complete the Services.  Client also acknowledges that the failure to maintain contact with the Firm may negatively impact the outcome of the Services.  The Client also authorizes the Firm to contact any Next of Kin.
  9. Client understands and acknowledges that the Firm is a collection of attorneys, and that the Firm cannot guarantee which of its attorneys will handle the case. Client agrees that the Firm may associate other counsel to assist in this representation.  If other counsel is associated, client agrees that the Firm may divide the total attorneys’ fees based on the sole judgment of the Firm without further notice to or consent of client, so long as such division of fees is in accord with rules governing the conduct of attorneys. 
  10. Client understands that the Client is solely responsible for all medical expenses incurred in connection with these Services. The Firm cannot prevent medical facilities from sending any outstanding balances to collections or filing a lien. Client further understands that the Firm is not obligated to pay Client’s medical expenses upon resolution of the case. However, the Firm may negotiate and pay Client’s medical expenses from the proceeds of the settlement upon mutual agreement with the Client.
  11. Client appoints the Firm as Client’s agent and attorney with authority to execute all receipts and/or releases, endorse all checks, drafts, and/or instruments in Client’s name/names necessary to effect settlement and Client confirms all actions of the Firm or agent.
  12. Client understands and agrees that 12 months after completion of the case, the Firm may discard file materials related to this representation.  Once that occurs, file materials may not be available from the Firm. 
  13. Client authorizes the Firm to file suit at any point when attorneys, in their sole discretion, determine that is in the best interest of the case. 
  14. Client agrees that the Firm has the right to withdraw from this representation at any time in the event the Firm determines the chances for a successful outcome do not justify proceeding further.

    This contract for legal services may be terminated at will at any time by either party upon written notification subject to the provisions below.  In the event Client terminates this contract, all unpaid costs and expenses shall immediately become due and payable.   


    The Firm shall be entitled to payment for Services rendered before the date of termination:   

    • If termination occurs with an offer pending, or after settlement or verdict, the Firm shall be entitled to the full percentage of the recovery as provided in the attorneys’ fees section above, with the understanding that those fees were earned; 
    • If termination occurs with no offer pending and there has been no settlement or verdict or award, the Firm may elect to charge a reasonable percentage based upon the amount of work performed or may elect to payment based upon the time devoted to the case at an hourly rate of $250.00 for attorneys and $150.00 for support staff.   

    In any event, Client grants the Firm a lien and security interest against any proceeds for all unpaid costs, expenses and fees.

  15. Client acknowledges and understands that there can be no changes made to the Services set forth above, unless the change is written in a new Letter of Engagement.
  16. The laws of the State of Georgia Rules of Professional Conduct of the State Bar of Georgia shall govern this Letter of Engagement. In addition, in the event of any dispute between the Client and the Firm, other than a dispute over Fees, Firm and Client agree that the dispute shall be settled exclusively by arbitration with an arbitration service provider agreed to by the parties.
  17. Client has read this contract and any questions have been addressed to client’s satisfaction.
  18. The client acknowledges the legal contents of this contract and is aware that their electronic signature is legally binding in the formation of this contract.

Sign Date:

Sign by:



Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Workers Comp 2023 English
lock iconUnique Document ID: 2d39a6fb66d36759a4f49ce850f9853643d90b4a
Timestamp Audit
January 19, 2023 1:14 pm EDTWorkers Comp 2023 English Uploaded by Taylor, Lee & Associates LLC - IP