Workers Compensation English Retainer Form

(Business & Professions Code §6147)

Client requests and authorizes Stephen F. Dial Esq., of Dial & Associates PC to represent him/her in all matters arising out of the accident occurring on:

against

Attorney's fees will be deducted from your settlement. The fee will be approved by the Workers' Compensation Appeals Board with consideration given to the: (1) responsibility assumed by the
attorney; (2) care exercised in representing you; (3) time involved; and, (4) results obtained. Attorney's fees typically are 15% of the benefits awarded. If at any time you no longer wish to be represented by
the attorney, you may withdraw from representation by notifying the attorney. If you withdraw from representation, the fee amount found by a workers' compensation judge to be the fair value of any work the attorney did in your case will be deducted from your award.

Client is informed that Attorney has entered into a written agreement to share fees with the referring law offices of

in the amount of

% of the total attorney fees charged by all lawyers is not increased solely by reason of the agreement to divide fees.

Nothing in this Agreement and nothing in Attorney’s or his employees’ statements to Client will be construed as a promise or guarantee about the outcome of the matter. Attorney makes no such promises or guarantees. Attorney’s comments about the outcome of the matter are expressions of opinion only, are neither promises nor guarantees and will not be construed as promises or guarantees.

I understand and agree that Dial & Associates PC is undertaking to represent me the Client in the above described case only insofar as may be necessary to litigate or negotiate the matter through settlement or award. Dial & Associates PC will not represent Client in any appeal or other matter not specified in this agreement. Any other litigation or appeal must be the subject of a separately negotiated agreement.

Dial & Associates PC has not been retained, unless otherwise agreed in writing, to present my spouse (if applicable) in any related claim or lawsuit against any person or entity for a claim for loss of consortium or any other theory of recovery.

I have also been advised that I should contact another attorney immediately in regard to any legal matter, and further, that the delay in the pursuit of any such other matter may harm investigative efforts.

Client may discharge attorney at any time. Attorney may discharge Client if a conflict arises, if Attorney is unable to effectively communicate with Client, or other reasons allowable by the California State Bar rules. If Client discharges Attorney, in the event we are discharged, we reserve the right to file a lien in the matter from which we are discharged for the amount of any fees to which we are entitled
by reason of our representation.

Pursuant to California Rule of Professional Conduct 1.4.2(a), Client is informed that the attorney does have professional liability insurance.

This Agreement contains the entire agreement of the parties. No other agreement, statement, or promise made on or before the effective date of this Agreement will be binding on the parties.

Although we maintain a paper hard copy of your file, Dial & Associates PC operates on a paperless basis, meaning that Dial & Associates stores your records electronically. We utilize off site email storage, and we use online and cloud-based document storage. While we use reasonable effort to maintain such records securely, and our vendors have covenanted to us that they will also make such reasonable efforts, we advise you that no computer system is free from risk of data breach.

When Attorney’s services conclude, whether by completing the services covered by this Agreement, or by discharge or withdrawal. Client may take possession of all of Client’s files including any property or items furnished by Client or otherwise relating to the services. The case file includes Client materials and property as defined in Rule 1.16(e)(1) of the California Rules of Professional Conduct.

Dial & Associates PC has the right to retain copies at our expense of all items contained in those files. If Client does not elect to take custody of the files, we will retain the paper files for what we consider to be a reasonable time at which time the files will be shredded of without further notice to you. Dial & Associates PC holds copies of your file electronically and accessible. If Client has not requested the return of Client’s file, and to the extent Attorney has not otherwise delivered it or
disposed of it consistent with Client’s directions, Attorney will retain the case file 30-days after termination of our engagement after which Attorney is authorized by this agreement to have the case
file destroyed.

Client may discharge Attorney at any time. Attorney may withdraw with Client’s consent or for good cause or if permitted under the Rules of Professional Conduct of the State Bar of California and/or
applicable law. Among the circumstances under which Attorney may withdraw are: (a) with the consent of Client; (b) Client’s conduct renders it unreasonably difficult for the Attorney to carry out the
employment effectively.

If a conflict arises and Client chooses to discharge Dial & Associates PC or if Dial & Associates PC chooses to discharge Client due to a conflict, from representation, upon signature of Acknowledgment
of Receipt of File and proper filings such as relieve Dial & Associates PC from representation of Client as attorney of record and filed and accepted by the respective Court, Client or his/her representative
attorney or designated party by the Client may take possession of Client’s file.

Client acknowledges receipt of a copy of this Agreement, having read its contents in its entirety, and Client understands and agrees with all of its provisions.

THE PARTIES HAVE READ AND UNDERSTOOD THE FOREGOING TERMS AND AGREE TO THEM AS OF THE DATE ATTORNEY FIRST PROVIDED SERVICES. IF MORE THAN ONE CLIENT SIGNS BELOW, EACH AGREES TO BE LIABLE, JOINTLY AND SEVERALLY, FOR ALL OBLIGATIONS UNDER THIS AGREEMENT. CLIENT WILL RECEIVE A FULLY EXECUTED COPY OF THIS AGREEMENT.