Free K-WC 160 - Statement Regarding Attorney Fees (Rev. 12-06) - Kansas

BEFORE THE DIVISION OF WORKERS COMPENSATION STATE OF KANSAS
VS. AND Claimant Respondent InsuranceCarrier ) ) ) ) ) ) ) ) ) ) ) )

DocketNo.

STATEMENT REGARDING ATTORNEY FEES
I__________________________________________________________representtheemployeeortheemployee'sdependentsin thisclaimandherebycertifythatthefollowingstatementshavebeencompletedbymeandaretrueandcorrecttothebestof myknowledgeandbelief: 1. Mywrittencontractofemploymentwiththeemployeeortheemployee'sdependentswasenteredintoonthe_________ dayof____________________,20_______,andatrueandcorrectcopythereofisattachedhereto. 2. Iclaimattorney'sfeesinthisclaiminthetotalamountof$_____________________________,whichis_________percent oftheamountofcompensationtoberecoveredandpaidonbehalfoftheemployeeortheemployee'sdependents. 3. Thefollowingoffersofsettlement,andthedatesthereof,weremadebyoronbehalfoftheemployeeortheemployee's dependentspriortothetimethatasettlementwasagreedtoamongtheparties:______________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Thefollowingoffersofsettlement,andthedatesthereof,weremadebyoronbehalfoftherespondentorinsurance carrierpriortoasettlementhavingbeenagreedtoamongtheparties:______________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. Approximately__________hourswereexpendedbymeinthecourseofthelegalrepresentationoftheemployeeorthe employee'sdependents.

K-WC160(Rev.12-06)

6. Thefollowingnovelordifficultlegalorfactualquestionswereinvolvedinthelegalrepresentationoftheemployeeorthe employee'sdependents:__________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 7. Theextenttowhichmyacceptanceoflegalrepresentationoftheemployeeortheemployee'sdependentsinthisclaim precludedotheremployment,ifsuchwasapparenttotheemployeeortheemployee'sdependents:_____________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ 8. Thefeecustomarilychargedinthislocalityforrepresentationsimilartomyservicesrenderedhereinis:_______________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ 9. Thefollowingtimelimitationswereimposedinthisclaimbytheemployee,theemployee'sdependentsorbythe circumstancesinvolved:______________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 10.Thefollowingsetsforthprioroccasionsuponwhichtheemployeeortheemployee'sdependentshavebeenrepresentedby me,thedatesthereof,andthegeneralnatureoftherepresentationinvolved:___________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ 11.Ihavebeenpracticingworkerscompensationlawfor________years. 12.Representationofclaimants,employersandinsurancecarriersinconnectionwithworkerscompensationclaims constitutes________percentofmytotalpracticeasanattorney.

____________________________________________________________ AttorneyfortheClaimant