ILLINOIS WORKERS COMPENSATION COMMISSION ATTORNEY REPRESENTATION AGREEMENT _______________________________________________ Case # ________ WC ____________________ Employee/Petitioner v. _______________________________________________ Employer/Respondent I, ______________________________________________ , "client," retain _ ____________________________________ , "attorney," to prosecute and/or settle any disputed claims for benefits under the Illinois Workers Compensation Act or Occupational Diseases Act against _____________________________________ __________ , "employer," for injuries arising out of and in the course of employment of ______________________________ _____________ on _____________________ . If the client has received a written offer from the employer or its agen t to pay a specific amount of compensation for any permanent disability caused by these injuries, the client has given the attorney a copy. The client and attorney each have a copy ofthat agreement, signed by both of them. In return for representation before the Commission, the client agrees to pay the attorney a sum of money equal to: A. 1._____ % of any amount received in excess of the written offer, if any, or ______ % (not to exceed 20%) of the total amount received for compensation for permanent disability caused by the accident, whichever is less; provided, however, if the compensation received for permanent disability does not exceed the w ritten offer, the attorney shall receive no fee for permanent disability; or 2.$ ________ (not to exceed $100) if the respondent does not dispute it s liability, the proper amount is paid timely, the client does not receive more than that specified by law, and the accident resul ted in any of the following: death of the employee; amputation of one or more fingers, toes, or body parts; removal of a tes ticle; enucleation or 100% loss of vision in an eye; fracture of one or more vertebra, spinous or transverse process, or faci al bones; fracture of a skull; removal of a kidney, spleen, or lung; and B. _____ % (not to exceed 20%) of any compensation for temporary total disability that the employer refused to pay in a timely manner or in the proper amount; and C. _____ % (not to exceed 20%) of all disputed medical bills; and D. In addition to the above, all costs and expenses of advocating the above claims. No settlement shall be made without the consent of the client. There wi ll be no charge unless recovery is made. If the client terminates this agreement before recovery, the client will pay the attorney a reasonable fee, as determined by theWorkers Compensation Commission, from the subsequent recovery (not to exceed the amounts listed in A-C above) plus any unpaid expenses related to advocating the claim up to the date the agree ment ended. This agreement is governed by the Illinois Workers Compensation Act, Se ction 16a, particularly in regard to the limitation ofattorneys fees in death, permanent total disability, and permanent part ial disability cases. The attorney states that he or she has explained each provision of this agreement to the client. The client states that he or she hasread and understands this agreement, and has received a copy of this agr eement on _________________________ . ___________________________________________________ ___________________________________________________ Signature of client Signature of attorney ___________________________________________________ ___________________________________________________ Name of client (please print) Name of attorney and IC code number (please print) ___________________________________________________ ___________________________________________________ Street address Name of law firm ___________________________________________________ ___________________________________________________ City State Zip code Firms address IC10 12/04 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free 866/352-3033 Web site: www.iwcc.il.govDownstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084 American LegalNet, Inc. www.USCourtForms.com