Statement Of Attorney Fees And Costs {SA04} | Pdf Fpdf Docx | Minnesota

 Minnesota   Workers Comp 
Statement Of Attorney Fees And Costs {SA04} | Pdf Fpdf Docx | Minnesota

Last updated: 8/25/2025

Statement Of Attorney Fees And Costs {SA04}

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Description

MN SA04 - STATEMENT OF ATTORNEY FEES AND COSTS. This form is used in Minnesota’s workers’ compensation system when an employee’s attorney requests payment for legal services and related expenses. The attorney must provide detailed information about the dispute, the benefits recovered for the employee, the hours worked, the hourly rate, and the types of fees being claimed (such as contingent fees, Roraff fees, Heaton fees, or fees for medical or rehabilitation issues). The form also requires disclosure of any prior attorney fee payments, expense advancements, or unsatisfied attorney liens, and it must include a proposed order for determining fees. Once served, the insurer, self-insured employer, or employee has ten days to file an objection if they dispute the requested amounts. If no objection is filed, the fees may be awarded. www.FormsWorkflow.com

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