AGREEMENT TO REPRESENT SUBROGATED INTEREST 1600 EAST CENTURY AVENUE, SUITE 1 P.O. BOX 5597 BISMARCK ND 58506-5597 TELEPHONE NUMBER (701) 328-3800 LEGAL DEPARTMENT FAX (701) 328-6040 TDD NUMBER (for the hearing impaired only) (701) 328-3786 www.WorkforceSafety.com WSI HelpLine 1-800-777-5033 Questions? Call us. Report Injuries Immediately. WORKFORCE SAFETY & INSURANCE LEGAL DIVISION ND Fraud and Safety Hotline 1-800-243-3331 SFN 50103 (05/2003) Report Fraud and Unsafe Work Conditions. I, , Attorney at Law, of the firm of agree to represent Workforce Safety & Insurance’s (WSI) subrogated interest, pursuant to provisions of N.D.C.C. section 65-01-09 in a third-party action involving the claim of , WSI claim number in connection with an injury on the 20 , day of , . It is agreed that: 1. Attorney fees and costs will be prorated in accordance with N.D.C.C. section 65-01-09. 2. Prior to incurring any costs exceeding One Thousand Dollars ($1,000), I will contact WSI for its approval. In the event an emergency should exist and an immediate commitment is required to protect the interest of the parties, I am hereby authorized to proceed according to my best judgment. 3. I will keep WSI informed of the status of the case, and will submit written status reports every six months or more often should the need arise. 4. WSI’s subrogated interest may not be reduced by settlement, compromise, or judgment, and WSI’s interest will be established strictly in accordance with N.D.C.C. section 65-01-09. 5. I will keep WSI informed of any settlement negotiations and will notify WSI in advance of any settlement conference. I will consult with WSI in advance of any proposed allocation of settlement proceeds to claims for loss of consortium. I will obtain WSI’s written approval prior to any settlement. (is not) a counterclaim. The claim (is) Dated this day of , 20 . day of , 20 . OF: Dated this Workforce Safety & Insurance Special Assistant Attorney General American LegalNet, Inc. www.FormsWorkflow.com