Utah > Workers Compensation
Appointment Of Counsel 152 - Utah
| Appointment Of Counsel Form. This is a Utah form and can be used in Workers Compensation . |
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Form 152 3/1/12 UTAH LABOR COMMISSION Division of Adjudication 160 East 300 South, 3rd Floor P O Box 146615 Salt Lake City, UT 84114-6615 casefiling@utah.gov * * APPOINTMENT OF COUNSEL * v. * Industrial Accident Date/ * Occupational Exposure Period _______________________________________________ * _________________________________________________ Respondent (Employer) * * ************************************ Petitioner hereby appoints the undersigned as my attorney to represent me in my industrial claim, effective immediately. I understand that I am not required to have an attorney in order to pursue my claim and that any questions I have may be answered, without charge, by representatives at the Labor Commission. I hereby appoint the undersigned as my attorney in this workers' compensation claim. I understand that the fee my attorney can receive is limited to the amount provided by Labor Commission Rule R602-2-4, which is amended from time to time (see http://www.laborcommission.utah.gov/). I also understand that the amount of my attorney's fees will be subtracted from any disability compensation awarded to me and that my attorney cannot charge me any other fee for services rendered in this matter. Date _________________________________________________ _______________________________________________________ Print Name of Attorney Bar Number _______________________________________________________ Attorney's Federal I.D. Number _______________________________________________________ Signature of Attorney _______________________________________________________ Street Address of Attorney _______________________________________________________ City/State/ Zip _______________________________________________________ Attorney's Telephone Number _______________________________________________________ Attorney's E-Mail Address Date __________________________________________________ ________________________________________________________ Printed Name of Petitioner ________________________________________________________ Petitioner's Social Security Number ________________________________________________________ Signature of Petitioner ________________________________________________________ Street Address of Petitioner ________________________________________________________ City/State/Zip _______________________________________________________ Petitioner's Telephone Number _______________________________________________________ Petitioner's E-Mail Address ________________________________________________ Petitioner UNSIGNED OR INCOMPLETE FORMS WILL BE RETURNED. American LegalNet, Inc. www.FormsWorkFlow.com
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