Legal Client Confidential Information Form
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:
