This is a convenient form injury lawyers can use to make sure they have everything covered when it comes to settling a case and getting everyone paid. We definitely recommend that beginners use this form so that you don’t leave anything out.

 

SETTLEMENT STATEMENT INFORMATION SHEET

[Client Name]

_________________________________________________

Client/Case Name

Today’s Date: [Date Completed]

SETTLEMENT FUNDS

Total Settlement Amount:

Name of Defendant(s) Paying the Settlement:

Insurance Company: EMC Insurance Company

Expected Date of Check(s):

Any Funds Paid Directly to Third Parties?

If yes, To Whom Paid:

Amount: $

FEE DISTRIBUTION

Total Fee:  %

Referring Lawyer Fee?

If yes, Name of Referring Lawyer:

Co-Counsel Fee Agreement:

Associate Attorney Fee?

If yes, Name of Associate Attorney:

Fee Split Agreement:  %/  %                  $          / $

LIENS/SUBROGATION

Medicare Involved?

Medicaid Involved?

3rd Party Liens

Health Insurance Subrogation Interest?

LIENS/SUBROGATION

Final Lien Amounts (Attach copy of lien/demand letter/invoice, if possible.):

OUTSTANDING EXPENSES

Reserve to be Held in Trust?

If yes, Amount?

Outstanding Invoices/Expert Fees:

Date of Last Federal Express Mailing, if any:

Date of Last American Express Charges, if any:

Date of Last Consult with Laura Rineberg/Nursing Research:

CLIENT FUNDS

Name(s) of Signer(s) on Settlement Statement: [Client Name] and [Spouse]

OTHER

Additional Info (Special Needs Trust, Special Instructions, etc.):  

 

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