Department of Industrial Relations Division of Workers' Compensation DISCLOSURE STATEMENT You are not required to be represented by an attorney in the handling of your workers' compensation case. If you choose to be represented by an attorney, your attorney's fees will be deducted from your benefits. Attorney's fees normally range from 9% to 12% of the benefits awarded. The actual amount of your attorney's fees will depend on the complexity of your case. The fee has to be approved by the Workers' Compensation Appeals Board. If your attorney has also represented you before the Rehabilitation Unit, there may also be a fee in conjunction with this representation. There are certain circumstances where your employer or his/her insurance carrier may be liable for the attorney's fees (Labor Code Section 4064) However, at no charge you may contact the Office of Benefit Assistance and Enforcement and talk to an Information and Assistance Officer regarding questions concerning you workers' compensation benefits. He/She may be ably to resolve your problems without the need for litigation. Call this toll-free number: 1-800736-7401. If you choose to be represented by an attorney, you and your attorney must sign this form. A copy of this form must be sent to your employer. (Labor Code Section 4906). If at any time you no longer wish to be represented by the attorney, you may withdraw from representation by notifying the attorney. If you withdraw from representation, you will still be responsible for the fee amount found by a workers' compensation judge to be the fair value of any work the attorney did in your case. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony. Toda aquella persona que sabiéndolo haga o cause que se produzca cualquier falsas o fraudulentas alegaciones o representaciones con el fin de obtener o negar beneficios o pagos de compensación de trabajadores lesionados es culpable de un crimen mayor. Employee's Signature Date Attorney's Signature Date Attorney: Give a copy to the employee. DWC Form 3 (1/1/90) 2000 © American LegalNet, Inc. 2001 © American LegalNet, Inc.