WID or SSN Minnesota Department of Labor and Industry Workers' Compensation Division PO Box 64218 St. Paul, MN 55164-0218 (651) 284-5030 1-800-342-5354 (DIAL-DLI)
R T 0 1
DATE(S) OF CLAIMED INJURY
DO NOT USE THIS SPACE
EMPLOYEE VS. EMPLOYER(S) AND INSURER(S) AND NAME OF ATTORNEY REQUESTING FEES
Employee or Insurer's Objection to Requested Attorney Fees and/or Costs
PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format.
Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers' compensation dispute. The data will be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department's file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative hearings; the workers' compensation court of appeals; the departments of revenue and health; and the workers' compensation reinsurance association.
1. I object to the attorney's request for (objection may be made to any requested fee or cost): Attorney fees in the amount of $ 2. The reasons for my objection are: Costs in the amount of $
NOTE: If a compensation judge is required to evaluate the reasonableness of the requested fees, the following factors will be considered. These factors may be used as a guideline to assist you in agreeing or objecting to the requested fees. · The dollar amount involved; · The time and expense necessary for case preparation; · The responsibility taken by the attorney; · The attorney's level of experience in and knowledge of workers' compensation; · How complicated the issues were; · How difficult the case was to prove and what the results were. 3. Do you request a hearing? No Yes, on attorney fees Yes, on costs
If a hearing is held, specify the language/dialect of any needed interpreter: If a reasonable accommodation of disability is requested for a hearing, describe:
(date) I mailed a copy of this form to the above-named attorney at the following address:
This form is being filed by SIGNATURE
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. MN RT01 (5/08)