Application For Lump Sum Payment Of Attorney Fees
Application For Lump Sum Payment Of Attorney Fees Form. This is a Ohio form and can be use in Industrial Commission Workers Comp.
Tags: Application For Lump Sum Payment Of Attorney Fees, IC-32-A, Ohio Workers Comp, Industrial Commission
APPLICATION FOR LUMP SUM PAYMENT OF ATTORNEY FEE The Industrial Commission of Ohio SUBMIT THIS FORM TO: Industrial Commission of Ohio Lump Sum Payments 30 W. Spring St. Columbus, Ohio 43215 Fax: (614) 466-7472 CLAIM NUMBER DATE OF INJURY ADDRESS ON APPLICATION IS NEW Employer's Address Injured Worker's Address Name Phone ( ) Name Phone ( ) Address Address City, State, Zip Code County Employer's Representative Injured Worker's Representative Name County City, State, Zip Code Phone ( ) Name Phone ( ) Address Address City, State, Zip Code County County City, State, Zip Code The undersigned attorney-at-law, duly authorized by the injured worker to represent him/her in the above captioned industrial claim, certifies that: (1) I have rendered the following services for this claim which were necessary to obtain the award for which the advancement to pay the fee is requested: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ (2) Should the Application for Lump Sum Payment, now under consideration, be granted, the injured worker will not be liable for any further fee with respect to continuing compensation, except where a later dispute would arise in this claim, requiring my additional services. (3) Should the Application for Lump Sum Payment include a request for reimbursement of expenses (not to exceed $1,000.00), a copy of the bill has been included with the application. ______________________________________________ Attorney's Signature (required) ________________________ Date I, the undersigned injured worker, am making application for a lump sum advancement for payment of attorney fees in the amount of $_____________. If the lump sum payment is granted by the Industrial Commission of Ohio, either wholly or in part, I request and authority is given to the Bureau of Workers' Compensation or self insuring employer to distribute the lump sum payment directly to the person or persons to whom payment is now due from me, pursuant to any Commission order. This payment will result in a reduction of weekly benefits from my Permanent Total Permanent Partial Death award. I certify that the above facts on my application are true. Injured Worker's Signature (required) IC-32-A An Equal Opportunity Employer And Service Provider Date OIC 3022 (Rev 11/08) American LegalNet, Inc. www.FormsWorkflow.com