Attorney Lien Notice

NOTICE OF ATTORNEY'S LIEN

Charging Lien / Notice of Representation

[LAW FIRM LETTERHEAD]

DATE: [________________________________]

VIA: Certified Mail, Return Receipt Requested
AND: Regular Mail / Email

TO:

Insurance Company:
[COMPANY NAME]
[CLAIMS DEPARTMENT]
[ADDRESS]
[CITY, STATE ZIP]

Claim Number: [________________________________]
Insured: [________________________________]
Date of Loss: [________________________________]

AND/OR:

Adverse Party/Counsel:
[NAME]
[ADDRESS]
[CITY, STATE ZIP]

RE: NOTICE OF ATTORNEY'S LIEN

Dear Sir or Madam:

Please be advised that this firm represents [CLIENT NAME] in connection with injuries and damages sustained on [DATE OF INCIDENT]. This letter gives notice of that representation and, only to the extent created and perfected under the authority identified below, asserts an attorney's lien.

I. NOTICE OF REPRESENTATION

This firm has been retained to represent the above-named client for all claims arising from the referenced incident. All communications regarding this matter should be directed to this office. Please do not contact our client directly.

Please update your records to reflect the following:

Attorney: [________________________________]
Firm: [________________________________]
Address: [________________________________]
Phone: [________________________________]
Fax: [________________________________]
Email: [________________________________]
File Reference: [________________________________]

II. NOTICE OF ATTORNEY'S LIEN

Subject to the jurisdiction-specific authority and perfection steps identified below, this firm claims an attorney's lien only against the property or proceeds covered by that authority.

Statutory Authority

This lien is claimed pursuant to:

☐ [STATE] [STATUTE NUMBER] (Attorney's Charging Lien Statute)
☐ Common law attorney's lien
☐ Contract between attorney and client (retainer agreement)
☐ Other: [________________________________]

Exact attachment/perfection requirements: [________________________________]

Required notice, filing, service, or commencement event: [________________________________]

Scope of Lien

Select only the categories covered by the cited authority and retainer agreement:

☐ Any settlement, judgment, or award paid to or on behalf of our client
☐ Any payment under liability policies issued to your insured
☐ Any payment under our client's own UM/UIM coverage
☐ Any payment under our client's MedPay/PIP coverage
☐ Any other compensation arising from this claim

Amount of Lien

This lien secures payment of:

☐ Attorney's fees as provided in our retainer agreement with our client
☐ Costs and expenses advanced on behalf of our client
☐ Any amounts owed by client to this firm arising from this representation

III. DEMAND FOR ACKNOWLEDGMENT

Without representing that acknowledgment alone creates or perfects a lien, we request that you:

1. Acknowledge receipt of this Notice of Attorney's Lien in writing.

2. Note in your file that no settlement payment should be made without including this firm as a co-payee or without our written consent.

3. Direct all settlement drafts as follows:
   - Make payable to: [CLIENT NAME] and [LAW FIRM NAME]
   - Mail to: [LAW FIRM ADDRESS]

4. Contact this office before making any direct contact with our client regarding settlement or payment.

IV. JURISDICTION-SPECIFIC CONSEQUENCES

The consequences of settlement or payment after notice depend on the controlling jurisdiction's lien law, the fee agreement, the property involved, and compliance with every required attachment, perfection, filing, and service step. This template does not assert automatic double liability, tort liability, co-payee status, or a right to block payment.

Insert the exact verified consequence, if any, and its controlling citation: [________________________________]

V. CLAIM SUMMARY

For your records, please note the following regarding our client's claim:

Type of Claim:
☐ Bodily Injury
☐ Property Damage
☐ Uninsured/Underinsured Motorist
☐ Medical Payments / PIP
☐ Other: [________________________________]

Injuries Claimed: [________________________________]

Treatment Status:
☐ Ongoing treatment
☐ Treatment completed
☐ Maximum medical improvement reached

Demand Status:
☐ Demand forthcoming
☐ Demand enclosed
☐ Previously submitted on [DATE]

VI. REQUEST FOR INFORMATION

To evaluate our client's claims, please provide the following:

☐ Confirmation of coverage for date of loss
☐ Policy limits (BI/PD/UM/UIM/MedPay)
☐ Copy of declarations page
☐ Claim number assignment
☐ Adjuster name and contact information
☐ Copy of insured's statement (if taken)
☐ Copy of police report (if obtained)

VII. CONTACT INFORMATION

Please direct all communications to:

[ATTORNEY NAME]
[LAW FIRM NAME]
[ADDRESS]
[CITY, STATE ZIP]

Phone: [________________________________]
Fax: [________________________________]
Email: [________________________________]

File Reference: [________________________________]

VIII. CONCLUSION

Thank you for your attention to this matter. Please acknowledge receipt of this Notice of Attorney's Lien within ten (10) days.

Very truly yours,

[SIGNATURE]

[ATTORNEY NAME]
Attorney for [CLIENT NAME]
[STATE BAR NUMBER]

cc:
☐ [CLIENT NAME]
☐ File

ACKNOWLEDGMENT OF ATTORNEY'S LIEN

TO: [LAW FIRM NAME]
FROM: [INSURANCE COMPANY/ADVERSE PARTY]
DATE: ______________

I/We acknowledge receipt of the Notice of Attorney's Lien dated [DATE] regarding the claim of [CLIENT NAME].

I/We acknowledge that:

☐ Any settlement payment will be made payable to both [CLIENT NAME] and [LAW FIRM NAME].

☐ No payment will be issued to [CLIENT NAME] individually without written consent from [LAW FIRM NAME].

☐ This acknowledgment has been noted in our claim file.

Claim Number: [________________________________]

Adjuster Name: [________________________________]

Adjuster Signature: _________________________________

Date: _________________________________

Phone: [________________________________]

Email: [________________________________]

NOTICE OF ATTORNEY'S LIEN - FILED WITH COURT

[COURT NAME] — [COUNTY], [STATE]

NOTICE OF ATTORNEY'S LIEN

TO ALL PARTIES AND THEIR ATTORNEYS OF RECORD:

PLEASE TAKE NOTICE that the undersigned attorney hereby claims a lien pursuant to [STATE STATUTE] upon any verdict, judgment, settlement, or other recovery in this action.

This lien is claimed for:

1. Attorney's fees under the contingency fee agreement between attorney and plaintiff;

2. All costs and expenses advanced on plaintiff's behalf; and

3. Any other amounts owed by plaintiff to the undersigned arising from this representation.

All parties and their insurance carriers are notified only of the lien claimed under the authority stated above. Any consequence of payment must be stated from the controlling law here: [________________________________].

DATED: [________________________________]

[SIGNATURE]

[ATTORNEY NAME]
Attorney for Plaintiff [CLIENT NAME]
[ADDRESS]
[PHONE]
[STATE BAR NUMBER]

CERTIFICATE OF SERVICE

I hereby certify that on [DATE], I served a copy of the foregoing Notice of Attorney's Lien on all parties by:

☐ First-class mail
☐ Electronic filing system
☐ Personal service
☐ Email

to the following:

[LIST OF PARTIES/COUNSEL SERVED]

[SIGNATURE]

[ATTORNEY NAME]

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