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)
P F 0 4
DATE(S) OF CLAIMED INJURY
DO NOT USE THIS SPACE
EMPLOYEE VS. EMPLOYER(S) AND INSURER(S)
Excess Fee Exhibit
AND (File this in addition to the Statement of Attorney Fees, if applicable.)
PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format.
I am the attorney for the employee, and I certify that the following statements are true: 1. The specific legal service(s) performed, the date(s) performed, and the number of hours spent for each service in representing the employee in the employee's workers' compensation claim described in the Statement of Attorney Fees and Costs served on (date) are: Attached to this Exhibit; or As follows:
2. I have the following experience and expertise in workers' compensation matters:
3. The following is a description of the factual and legal issues in dispute:
4. The nature of proof required in this case and the responsibility assumed by me was as follows:
MN PF04 (5/08)
5. The following additional information should be considered in determining attorney fees:
6. At this time a hearing on the matter of attorney fees
is not requested.
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:
ATTORNEY FOR EMPLOYEE
ATTORNEY FOR EMPLOYEE SIGNATURE
ATTORNEY REGISTRATION NUMBER
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.