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DESIGNATION OF COUNSEL
To:
(name of requesting party)
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Authorization:
Pursuant to Section 2695.2 (c) of the California Code of Regulations, Title 10 Chapter 5, I authorize BAUSCH LAW GROUP, A PROFESSIONAL CORPORATION, my attorney to handle my personal injury and property damage claim arising out of accident that occurred on
DATE OF INJURY *
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Time
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Authorization:
BAUSCH LAW GROUP PC is authorized to handle all the relevant legal matters on my behalf, including but not limited to defending and/or filing and maintaining a lawsuit(s), obtaining records of any kind or type, engaging in settlement negotiations, and signing and depositing checks on my behalf, however only into client/trust fund accounts.

This authorization shall be valid for two years from the date of the aforementioned accident unless renewed or revoked by the undersigned. Any and all prior authorizations are hereby revoked by the undersigned as of the date of this authorization.

A photocopy of this designation shall be considered as valid as the original.

Client's Signature: *
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Client’s Name: *
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Dated: *
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Address: *
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City, State, ZIP: *
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Telephone: *
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Email:
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