Attorney Certification For No Liability Stipulations
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Attorney Certification For No Liability Stipulations Form. This is a Georgia form and can be use in Workers Comp.
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WC-15 ATTORNEY CERTIFICATION FOR NO LIABILITY STIPULATIONS
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
ATTORNEY CERTIFICATION FOR NO LIABILITY STIPULATIONS
Board Claim No.
Employ ee Last Name
Employ ee First Name
M.I.
SSN or Board Tracking #
Date of Injury
As counsel of record for the employee in the above referenced claim(s), I,
,
hereby certify and affirm my claim for reimbursable expenses is in compliance with and permitted by Rule 1.8(e) of the Georgia Rules
of Professional Conduct, Board Rule 108 and Board Rule 15 and that I am charging a fair and reasonable fee to my client whi ch does
not exceed 25% as allowed by O.C.G.A. 34-9-108 and Board Rule 108 as they apply to the alleged accident date(s) of :
This
day of
(Day)
.
/
(Month)
(Year)
Print Name
Address
Signature
Telephone Number
City
GA Bar Number
State
Zip Code
IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF W ORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov
WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19).
WC-15
REVISION . 07/2011
15
ATTORNEY CERTIFICATION
FOR NO LIABILITY STIPULATIONS
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