Kentucky > Workers Comp
Attorney Fee Election 109 - Kentucky
| Attorney Fee Election Form. This is a Kentucky form and can be used in Workers Comp . |
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Form 109 Attorney Fee Election Adopted March 15, 1995 DEPARTMENT OF WORKERS CLAIMS FRANKFORT, KENTUCKY 40601 States File: STANDARD FORM FOR Number Carrier: ATTORNEY FEE ELECTION For: Employer: Carriers File No. I hereby certify that my attorney has fully explained to me my options regarding the payment of attorney fees. I hereby sect thel e following method: A. _____ I eect tol pay my attorneys fee out of my personal funds. B. _____ I eect tol have any attorneys fee paid in a lump sum and to haeachve of my weekly benefits equally reduced until the defendants have recouped the amount of my attorneys fee. C. _____ My case has been settled for a lump sum. I eect tol pay my attorneys fee out of my lump sum settlement. , plaintiff herein, being duly sworn, states thatthe statement of the foregoing eectil on is true. Plaintiff SUBSCRIBED AND SWORN to before me this day of , 20 . Notary Public or other authorized officerI hereby certify that I have fully explained the provisions of KRS 342.320 to my client. Attorney for Plaintiff
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