Free WORKER'S SETTLEMENT STATEMENT - Michigan

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WORKER'S SETTLEMENT STATEMENT
Michigan Department of Labor & Economic Growth Workers' Compensation Agency PO Box 30016, Lansing, MI 48909
Plaintiff v. 1a. Current Settlement Payment 1b. 70% Benefits Paid (if any) 1c. Total Redemption Settlement Amount ATTORNEY EXPENSES UNDER R408.44(5) 2a. 2b. 2c. 2d. 2e. Total Expenses ATTORNEY FEE CALCULATION UNDER R408.44(3)(4)(7) 3a. 3b. 3c. 3d. 3e. 4. % X Total Attorney Fee Redemption Fee Base for Fee Calculation (Total Redemption Minus Total Expenses) % of first $25,000 % above $25,000 = = = $ $ $ $ $ $ $ $ Defendant

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$ $ $ $ $ $ 100.00

DIRECT PAYMENTS 5a. 5b. 5c. 5d. 6. 7. 8. Total Direct Payments 70% Benefits Paid $ $ $ $ $ $ $

Total Expenses, Attorney Fees, Redemption Fee, Direct Payments and 70% Benefits Net Amount to Plaintiff (1c minus 7)

Date

I certify that I have read and approved of this statement. Plaintiff Attorney for Plaintiff

The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. WC-544 (Rev. 7/05) AUTHORITY R408.44(3)