Office of Administrative Hearings Workers222 Compensation Division PO Box 64620 St. Paul, MN 55164-0620 (651) 361-7900 Reset RT01 DO NOT USE THIS SPACE Employee or Insurer222s Objection to Requested Attorney Fees and/or Costs PRINT IN INK or TYPE Enter dates in MM/DD/YYYY Format Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers222 compensation dispute. The data will be used by the office of administrative hearings (OAH) and the department of labor and industry staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department222s file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the workers222 compensation court of appeals; the departments of revenue and health; and the workers222 compensation reinsurance association. 1. I object to the attorney222s request for (objection may be made to any requested fee or cost): Attorney fees in the amount of $ Costs in the amount of $ 2. The reasons for my objection are: NOTE: If a compensation judge is required to evaluate the reasonableness of the requested fees, the following factors will be considered. These factors may be used as a guideline to assist you in agreeing or objecting to the requested fees. 225 The dollar amount involved; 225 The time and expense necessary for case preparation; 225 The responsibility taken by the attorney; 225 The attorney222s level of experience in and knowledge of workers222 compensation; 225 How complicated the issues were; 225 How difficult the case was to prove and what the results were. 3. Do you request a hearing? No Yes, on attorney fees Yes, on costs If a hearing is held, specify the language/dialect of any needed interpreter: If a reasonable accommodation of disability is requested for a hearing, describe: 4. On (date) I mailed a copy of this form to the above-named attorney at the following address: This form is being filed by employee insurer: This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS222 COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. MN RT01 (6/18) DATE SIGNATURE WID or SSN DATE(S) OF CLAIMED INJURY EMPLOYEE VS. EMPLOYER(S) AND INSURER(S) AND NAME OF ATTORNEY REQUESTING FEES American LegalNet, Inc. www.FormsWorkFlow.com