Form 109 Attorney Fee Election Adopted March 15, 1995 DEPARTMENT OF WORKERS CLAIMS FRANKFORT, KENTUCKY 40601 STANDARD FORM FOR State's File Number: Carrier For: ATTORNEY FEE ELECTION Employer: Carrier's File No. I hereby certify that my attorney has fully explained to me my options regarding the payment of attorney fees. I hereby select the following method: A. B. I elect to have any attorney's fee paid in a lump sum and to have each of my weekly benefits equally reduced until the defendants have recouped the amount of my attorney's fee. C. My case has been settled for a lump sum. I elect to pay my attorney's fee out of my lump sum settlement. I elect to pay my attorney's fee out of my personal funds. , plaintiff herein, being duly sworn, states that the statement of the foregoing election is true. Plaintiff SUBSCRIBED AND SWORN to before me this , 20 . day of Notary Public or other authorized officer I hereby certify that I have fully explained the provisions of KRS 342.320 to my client. Attorney for Plaintiff American LegalNet, Inc. www.FormsWorkFlow.com