Legal

Complete power of attorney online

For representation in a legal matter · Prefer to download and print? · This is a translation; the Dutch version prevails.

Complete the power of attorney below and sign with your mouse, trackpad or finger. After sending, Juridisch Adviesbureau Rogerius B.V. receives the signed power of attorney as a PDF and you receive a copy at the email address you provide. Fields marked * are required.

1. Principal (client)

Surname and initials * Date of birth *

Address *

Postcode * Town *

Telephone number Email address *

The principal is a legal entity (company, foundation, association)

2. Attorney-in-fact

Juridisch Adviesbureau Rogerius B.V.
Chamber of Commerce (KvK) 88261174
Bernhardlaan 24, 6133 BK Sittard, Nederland
represented for this purpose by its director and/or the employees designated by it.

3. Matter Description of the matter * Opposing party (name and address) Reference / file number

4. Scope of authority

The principal authorises the attorney-in-fact to perform the acts ticked below on the principal’s behalf in the above matter. Untick what you do not permit.

Request and receive information and documents from the opposing party, (former) employer, UWV, municipality, insurer, legal expenses insurer or other relevant bodies. Conduct correspondence, consultations and negotiations with the opposing party and relevant third parties. Negotiate a settlement agreement (vaststellingsovereenkomst) or other arrangement, subject to Article 5. Lodge objections and administrative appeals with public authorities (such as UWV or the municipality) and represent the principal therein. Represent the principal in proceedings before the Dutch subdistrict court (kantonrechter), insofar as representation by a lawyer is not mandatory. Other, namely:

Special categories of personal data. Only if ticked below, the principal gives explicit consent for data concerning his or her health (such as information from the company doctor, occupational health service or UWV insurance physician) to be requested, received and used, solely insofar as necessary for this matter:

Yes, I give this explicit consent. I may withdraw this consent at any time.

5. Limitations

The attorney-in-fact will perform the following acts only with the prior, express and written (including by email) consent of the principal:

entering into or signing a settlement agreement, compromise or other arrangement;
waiving rights or acknowledging liability;
terminating an employment contract or agreeing to its termination;
withdrawing an objection, appeal or proceedings;
delegating this authority to a third party, such as a lawyer (substitution).

Payments by the opposing party or third parties in this matter shall be made directly to the principal, unless agreed otherwise in writing.

6. Duration and termination

This power of attorney applies from the date of signing until the matter is concluded. The principal may revoke it in writing at any time. It also ends in the cases set out in Article 3:72 of the Dutch Civil Code (Burgerlijk Wetboek). Acts performed within the limits of this power of attorney before revocation remain valid.

7. Declarations by the principal

The principal undertakes to inform the attorney-in-fact fully and truthfully of all facts relevant to the matter.
The principal agrees that the attorney-in-fact may show this power of attorney to third parties or provide a copy, insofar as necessary for its performance.
The principal’s personal data are processed in accordance with the General Data Protection Regulation (GDPR) and used solely for the performance of this power of attorney and the services of the attorney-in-fact.
The services are subject to the engagement letter and any general terms and conditions of the attorney-in-fact.
This power of attorney is governed by Dutch law. In the event of any discrepancy between this translation and the Dutch version, the Dutch version prevails.

I have read Articles 5, 6 and 7 and agree to them. *

8. Signatures

Completed truthfully and signed:

Place * Date *

Signature of the principal *

Sign with your mouse, trackpad or finger.

The attorney-in-fact signs for acceptance upon receipt.

Security question: what is 3 + 4? *

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