LEGAL CLIENT CONFIDENTIAL INFORMATION FORM
Please complete this form accurately and sign the confidentiality agreement. Thank you for entrusting [Your Company Name] with your legal matters.
Client Information:
Full Name: [Client Name]
Address: [Client Address]
Phone Number: [Client Phone Number]
Email Address: [Client Email]
Date of Birth: [Date]
Social Security Number: [SSN]
Legal Matter Details:
Field | Information |
|---|
Case/Reference Number | CR-2024-001 |
Type of Legal Matter | Personal Injury |
Description of Legal Issue | Car accident involving a pedestrian |
Date of Incident/Accrual | 02/15/2024 |
Relevant Documents | Police report, medical records |
Witnesses | Sarah Smith, David Johnson |
Opposing Party | Yellife Insurance Company |
Relevant Dates | Accident date: 02/15/2024 Medical treatment: 02/16/2024 |
I, [Client Name], understand and acknowledge that the information provided on this form and any information disclosed during the course of my legal representation by [Your Company Name] is confidential. I agree that [Your Company Name] will not disclose any information provided by me to any third party, except as required by law or with my express consent.
Client's Signature:
Date:
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