STATE OF MONTANA MAIL ROOM DATE DEPARTMENT OF LABOR AND INDUSTRY EMPLOYMENT RELATIONS DIVISION ATTORNEY RETAIN ER AGREEMENT P.O. BOX 8011 HELENA, MT 59604-8011 INSTRUCTIONS: Complete the form and return to Department for approval. Attorney: Claimant: Address: Address: City/State/Zip: City/State/Zip: Date (s) of Accident: Phone: Employers: The above-named claimant hereby employs the above-named attorney an d the attorney agrees to represent claimant in his claim for workers compensation or occupational disease benefits arising out of an industrial a ccident or occupational disease suffered b y the claimant on or about the above-noted day while employed by the above-noted employer and claimant hereby requests that the Department of Labor and Industry enter the attorney as attorney of record, direct all future correspondence to said attorney an d furnish said attorney all pertinent documents in claimants file upon request. Check A, B, or C as applicable: A. Claimant and attorney agree to a fee schedule as follows: For cases that have been settled without an order of the wo rkers compensation judge or the Supreme Court twenty percent (20%) of the amount of additional compensation payments the claimant receives due to the efforts of the attorney. For cases that go to a hearing before the workers compensat ion judge or the Supreme Court, twenty-five percent (25%) of the amount of additional compensation payments the claimant receives from an order of the workers compensation judge or the Supreme Court due to the efforts of the attorney. B. Claimant and attorney agree that claimant shall pay for services rendered by attorney on behalf of claimant at the rate of $ per hour (not more than $100.00 per hour); provided that the total fee shall not exceed the percentages set forth above in subsection A. C. Application is made for approval of a variance from the guideline fees to charge at the rate of . Documentation for the requested variance is attached. If the variance is no t approved, the attorney and the claimant agree to a fee of A or B, as set forth above. Where the initial compensability of the claim is not in dispute, no fee shall be charged upon temporary total disability benefits paid during the healing period or upon medical benefits. If the insurer has denied liability, the attorney fee shall apply to all monies, including medical benefits, obtained for the claimant through the efforts of the attorney. The following benefits shall not be considered as a basis for calculation of attorney fees: (1) The amount of medical and hospital benefits received by the claimant, unless the workers compensation insurer has denied all liability, including medical and hospital benefits, or unless the insurer has denied the payment of certain medical and hospital costs and the attorney has been successful in obtaining such benefits for the claimant. (2) Benefits received by the claimant wi th the assistance of the attorney in filling out initial claim forms only. (3) An undisputed portion of impairment benefits received by the claimant based on an impairment rating. (4) Benefits initiated or offered by the insurer when such initiation or offer is supported by documentation in the claimants file and has not been the subject of a dispute with the claimant. (5) Any other benefits not obtained due to the actual, reasonable and necessary efforts of the attorney. The claimant agrees to pay or reimburse all costs incurred by the attorney in investigating and prosecuting the claim. Claimant does hereby authorize the attorney to act on his behalf exercising all powers authoriz ed by the laws of the State of Montana relating to the attorney-client relationship. It is understood by the claimant that the attorney may select co-counsel as the attorney believes necessary and expeditious in handling the claim, and that any payment received by co-counsel shall be made by sharing the above-refere nced fee between the attorney and the co-counsel. In the event a dispute arises between any cl aimant and the claimants attorney relative to attorneys fee in a workers compensation claim, upon request of either the claimant or the attorney, or upon notice of any party of a violation of Section 39-71-613, MCA or ARM 24.29.3802, the Administrato r or his designee, shall review the matter and issue his order resolving the dispute pursuant to procedures set forth in ARM 24.29.201, et seq. The attorney and claimant understand that the Department retains its authority to regulate the attorney fee amount in any workers compensation case even though the contract of employment fully complies with Section 39-71-613, MCA, and ARM 24.29.3802. Claimant acknowledges a copy of this agreement and agree s that a copy be filed with the Department of Labor and Industry. DATED: SOCIAL SECURITY #: ____________________________________ _______________________________ ATTORNEY SIGNATURE CLIENT SIGNATURE LOWER PORTION TO BE COMPLETED BY DEPARTMENT ONLY This agreement is hereby:
APPROVED
A
B
C
NOT APPROVED INITIALS: __________________ DATE: _____________________ ERD050 (New 02/90) Rev. 5/95