Kansas > Workers Compensation
Statement Regarding Attorney Fees K-WC 160 - Kansas
| Statement Regarding Attorney Fees Form. This is a Kansas form and can be used in Workers Compensation . |
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KANSASDEPARTMENTOFLABOR www.dol.ks.gov Page1of2 STATEMENT REGARDING ATTORNEY FEES K-WC160(Rev.6-12) VS. AND Claimant Respondent InsuranceCarrier BEFORETHEDIVISIONOFWORKERSCOMPENSATION STATEOFKANSAS ) ) ) ) ) ) ) ) ) ) ) ) DocketNo. STATEMENTREGARDINGATTORNEYFEES I__________________________________________________________representtheemployeeortheemployee's dependentsinthisclaimandherebycertifythatthefollowingstatementshavebeencompletedbymeandaretrueand correcttothebestofmyknowledgeandbelief: 1. Mywrittencontractofemploymentwiththeemployeeortheemployee'sdependentswasenteredintoonthe _________dayof____________________,20_______,andatrueandcorrectcopythereofisattachedhereto. 2. Iclaimattorney'sfeesinthisclaiminthetotalamountof$_____________________________,whichis_________ percentoftheamountofcompensationtoberecoveredandpaidonbehalfoftheemployeeortheemployee's dependents. 3. Thefollowingoffersofsettlement,andthedatesthereof,weremadebyoronbehalfoftheemployeeorthe employee'sdependentspriortothetimethatasettlementwasagreedtoamongtheparties:_______________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 4. Thefollowingoffersofsettlement,andthedatesthereof,weremadebyoronbehalfoftherespondentorinsurance carrierpriortoasettlementhavingbeenagreedtoamongtheparties:________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 5. Approximately__________hourswereexpendedbymeinthecourseofthelegalrepresentationoftheemployeeor theemployee'sdependents. DIVISIONOFWORKERSCOMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone:(785)296-4000·Fax:(785)296-8580·Email:wc@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com Statement Regarding Attorney Fees K-WC160(Rev.6-12) KansasDepartmentofLabor Page2of2 6. Thefollowingnovelordifficultlegalorfactualquestionswereinvolvedinthelegalrepresentationoftheemployeeor theemployee'sdependents:__________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 7. Theextenttowhichmyacceptanceoflegalrepresentationoftheemployeeortheemployee'sdependentsinthis claimprecludedotheremployment,ifsuchwasapparenttotheemployeeortheemployee'sdependents:_____________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ 8. Thefeecustomarilychargedinthislocalityforrepresentationsimilartomyservicesrenderedhereinis:___________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ 9. Thefollowingtimelimitationswereimposedinthisclaimbytheemployee,theemployee'sdependentsorbythe circumstancesinvolved:_____________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 10. Thefollowingsetsforthprioroccasionsuponwhichtheemployeeortheemployee'sdependentshavebeen representedbyme,thedatesthereofandthegeneralnatureoftherepresentationinvolved:________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ ___________________
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