KANSASDEPARTMENTOFLABOR www.dol.ks.gov Page1of2 STATEMENT REGARDING ATTORNEY FEES K-WC160(Rev.10-12) VS. AND Claimant Respondent InsuranceCarrier BEFORETHEDIVISIONOFWORKERSCOMPENSATION STATEOFKANSAS ) ) ) ) ) ) ) ) ) ) ) ) DocketNo. STATEMENTREGARDINGATTORNEYFEES I,__________________________________________________________,representtheemployeeortheemployee's dependentsinthisclaimandherebycertifythatthefollowingstatementshavebeencompletedbymeandaretrueand correcttothebestofmyknowledgeandbelief: 1. Mywrittencontractofemploymentwiththeemployeeortheemployee'sdependentswasenteredintoonthe _________dayof____________________,20_______,andatrueandcorrectcopythereofisattachedhereto. 2. Iclaimattorney'sfeesinthisclaiminthetotalamountof$_____________________________,whichis_________ percentoftheamountofcompensationtoberecoveredandpaidonbehalfoftheemployeeortheemployee's dependents. 3. Thefollowingoffersofsettlement,andthedatesthereof,weremadebyoronbehalfoftheemployeeorthe employee'sdependentspriortothetimethatasettlementwasagreedtoamongtheparties: 4. Thefollowingoffersofsettlement,andthedatesthereof,weremadebyoronbehalfoftherespondentorinsurance carrierpriortoasettlementhavingbeenagreedtoamongtheparties: 5. Approximately__________hourswereexpendedbymeinthecourseofthelegalrepresentationoftheemployeeor theemployee'sdependents. DIVISIONOFWORKERSCOMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone:(785)296-4000·Fax:(785)296-8580·Email:wc@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com Statement Regarding Attorney Fees K-WC160(Rev.10-12) KansasDepartmentofLabor Page2of2 6. Thefollowingnovelordifficultlegalorfactualquestionswereinvolvedinthelegalrepresentationoftheemployeeor theemployee'sdependents: 7. Theextenttowhichmyacceptanceoflegalrepresentationoftheemployeeortheemployee'sdependentsinthis claimprecludedotheremployment,ifsuchwasapparenttotheemployeeortheemployee'sdependents: 8. Thefeecustomarilychargedinthislocalityforrepresentationsimilartomyservicesrenderedhereinis: 9. Thefollowingtimelimitationswereimposedinthisclaimbytheemployee,theemployee'sdependentsorbythe circumstancesinvolved: 10. Thefollowingsetsforthprioroccasionsuponwhichtheemployeeortheemployee'sdependentshavebeen representedbyme,thedatesthereofandthegeneralnatureoftherepresentationinvolved: 11. Ihavebeenpracticingworkerscompensationlawfor________years. 12. Representationofclaimants,employersandinsurancecarriersinconnectionwithworkerscompensationclaims constitutes________percentofmytotalpracticeasanattorney. ____________________________________________________________ Attorneyfortheclaimant DIVISIONOFWORKERSCOMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone:(785)296-4000·Fax:(785)296-8580·Email:wc@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com