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
Today’s Date: [Date Completed]
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:
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: %/ % $ / $
3rd Party Liens
Health Insurance Subrogation Interest?
Final Lien Amounts (Attach copy of lien/demand letter/invoice, if possible.):
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:
Name(s) of Signer(s) on Settlement Statement: [Client Name] and [Spouse]
Additional Info (Special Needs Trust, Special Instructions, etc.):