WC-108a ATTORNEY FEE APPROVAL GEORGIA STATE BOARD OF WORKERS' COMPENSATION ATTORNEY FEE APPROVAL Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION EMPLOYEE County of Injury Address E-mail Address City State Zip Code B. REQUEST FOR APPROVAL OF ATTORNEY FEE CONTRACT Counsel for the employee/claimant requests approval of the attached fee contract which calls for payment of percent (not to exceed 25%) of all income benefits (which are/have been paid in the amount of $ / commencing (month) / per week) for a period not to exceed (day) weeks. (Attach supporting documentation) (year) Counsel for the employee / claimant , other: requests assessment of his / her fee and / or reasonable litigation expenses by consent of parties based on: Reasonable value of services in the amount of $ . Percent (not to exceed 25%) of all income benefits (which are / have been paid in the amount of $ / commencing (month) per week.) / (day) for a period not to exceed weeks. (year) Reasonable litigation expenses in the amount of $ . (Attach supporting documentation) D. AGREEMENT OF ALL PARTIES AND COUNSEL FOR RESOLUTION OF FEE LIEN DISPUTE All parties and counsel agree for the Board to approve payment of fees as follows: Specify which attorney should receive which fee, and whether the fee should be assessed as a lump sum amount or as percentage based on income benefits, the date commenced, and the percentage to be applied (not to exceed 25%). E. CERTIFICATION I certify the fee which I am requesting represents the fair and reasonable value of my services, and complies with O.C.G.A. 34-9-108 and Board Rule 108. I have today sent a copy of this request to all counsel and unrepresented parties in this action. Signature Date Signature Print Name Date Print Name E-mail GA Bar Number Address City CONSENTED TO BY: E-mail GA Bar Number Address State Zip Code City State Zip Code -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-108a REVISION . 07/2011 108a ATTORNEY FEE APPROVAL