STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION APPEALS BOARD ID OR CASE NO. PETITION FOR ORDER ALLOWING PRE-APPLICATION ATTORNEY FEE AND ORDER Injured Worker Date of Claimed Injury Address Social Security Number Date of Birth Attorney for Injured Worker Address Employer Address Insurance Carrier or, If Self-Insured, Certificate Name Address Where Claim Administered Adjusting Agency, if Agency Administered Attorney for Employer/Carrier Address Description of services rendered (nature of dispute, responsibility assumed, complexity or unusual difficulties and results obtained): Date of request Certified specialist? Estimate of time involved Attorney fee requested $ Yes No Manner of payment (See instructions): ` Attorney or Representative Address Telephone No. Attorney fee previously received on this claim and other related claims or Applications for Adjudication (list Applications by case number): A COPY OF THE DATED AND COMPLETED EMPLOYEE'S CLAIM FOR WORKERS' COMPENSATION BENEFITS (FORM DWC1) AND THE ATTORNEY FEE DISCLOSURE STATEMENT (FORM DWC-3) MUST BE ATTACHED TO THIS FEE REQUEST AND A COPY OF THE FEE REQUEST MUST BE SERVED ON THE INJURED WORKER, THE EMPLOYER AND INSURANCE CARRIER OR ADJUSTING AGENCY PURSUANT TO APPEALS BOARD RULE 10975. WCAB FORM 31 (REV. 2/91) (Page 1 of 2) 2002 © American LegalNet, Inc. ORDER The above fee request is approved in the amount of $ _____________. is ordered to pay this amount to: (Employer/Insurance Carrier/Claimant) . Dated: ______________________ _____________________________________________________ Workers' Compensation Judge SERVED ON THE FOLLOWING: By: ________________________________ Date: ______________________________ INSTRUCTIONS Labor Code Sections 490t6(b) and (c) provide: "No attorney or agent shall demand or accept any fee from an employee or dependent of an employee for the purpose of representing the employee or dependent of an employee in any proceeding of the division, appeals board, or any appellate procedure related thereto until the amount of the fee has been approved or set by the appeals board. "Any fee agreement shall be submitted to the appeals board for approval within 10 days after the agreement is made" Any request for attorney fees for services rendered after the filing of the Employee's Claim for Workers' Compensation Benefits for but before the filing of an Application for Adjudication must be on this form which shall be completely filled out. The manner of payment shall be indicated by including the name of the person or other legal entity to make the payment, the method of payment and the attorney or law firm receiving payment. Any funds or proceeds out of which payment is to be made will clearly be set forth. WCAB FORM 31 (REV. 2/91) (Page 2 of 2) 2002 © American LegalNet, Inc.