THIRD PARTY NOTICE OF LEGAL REPRESENTATION LEGAL DIVISION SFN 7700 ( 0 8 / 2014 ) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506 - 5585 Telephone 1 - 800 - 777 - 5033 Toll Free Fax 1 - 888 - 786 - 8695 TTY (hearing impaired) 1 - 800 - 366 - 6888 Fraud and Safety Hotline 1 - 800 - 243 - 3331 www.WorkforceSafety.com NOTICE TO WORKFORCE SAFETY & INSURANCE Pursuant to Section 65-01-09 of the North Dakota Century Code, I, the undersigned, hereby notify Workforce Safety & Insurance (WSI) that I intend to bring an action against a third party whom I feel is responsible for the injuries suffered by me on (date) , 20 . I agree that I will act as trustee for WSI for its subrogated interest, pursuant to statute, in this case. I hereby notify WSI that I have employed , Attorney at Law, of the firm of at (address) to represent me in this third party action against (third party name), (address). I hereby authorize and request WSI to reveal to my attorney any or all information in my claim file number . Lien Notice: WSI has a lien in the full amount it has paid in all benefits for this claim. This lien attaches to all claims, demands, settlement proceeds, judgment awards, or insurance payable by reason of a legal liability of a third person. If you receive any money in regard to this claim from a third person or their insurance company, and WSI does not receive payment of its lien within thirty days of their payment to you, WSI may sue you and/or your personal injury attorney for the full amount of the lien. No release of liability or satisfaction of any judgment, claim or demand is valid or Signature of Injured Worker Date American LegalNet, Inc. www.FormsWorkFlow.com