PETITION FOR APPROVAL OF ATTORNEY'S FEES

(Workers' Compensation Fee Application)

[// GUIDANCE: Attorney fees in workers' compensation cases are regulated by state law and must be approved by the Workers' Compensation Judge. Fees are typically contingent (percentage of benefits recovered) and subject to statutory caps (e.g., 15% in California, 20% in Pennsylvania, 25% in Georgia). This petition requests judicial approval of the attorney's fee.]

PART 1: CASE INFORMATION

WCAB/Board Case Number: [NUMBER]

Claim Number: [NUMBER]

Date of Petition: [DATE]

Date of Injury: [DATE]

PART 2: PARTIES

2.1 Applicant (Injured Worker)

Name: [FULL NAME]

Date of Birth: [DATE]

Social Security Number: [XXX-XX-XXXX]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

2.2 Employer (Defendant)

Employer Name: [NAME]

Address: [ADDRESS]

2.3 Insurance Carrier

Carrier Name: [NAME]

Claim Number: [NUMBER]

Address: [ADDRESS]

PART 3: ATTORNEY INFORMATION

3.1 Applicant's Attorney (Petitioner)

Attorney Name: [NAME]

State Bar Number: [NUMBER]

Firm Name: [FIRM NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

Fax: [FAX]

Email: [EMAIL]

3.2 Fee Agreement

Date of Fee Agreement: [DATE]

Type of Fee Agreement:
☐ Contingency Fee Agreement
☐ Hourly Fee Agreement
☐ Hybrid Agreement

Agreed Fee Percentage: [___]%

Fee Agreement Attached: ☐ Yes ☐ No

PART 4: BENEFITS OBTAINED

4.1 Summary of Benefits Secured

[// GUIDANCE: List all benefits obtained through attorney's representation]

4.2 Benefits Subject to Attorney Fee

[// GUIDANCE: Not all benefits are subject to attorney fees. Generally, fees are calculated on indemnity benefits, not medical treatment value.]

PART 5: FEE CALCULATION

5.1 Requested Fee

Fee Percentage: [___]%

Fee Base (Benefits Subject to Fee): $[AMOUNT]

Calculated Fee: $[AMOUNT]

Maximum Statutory Fee ([STATE]): [___]%

REQUESTED ATTORNEY FEE: $[AMOUNT]

5.2 Fee Breakdown (if multiple components)

5.3 State Statutory Limits

[// GUIDANCE: Insert applicable state fee limits]

California: Maximum 15% of indemnity benefits (Lab. Code § 4906)

Texas: Maximum 25% of recovery, subject to DWC approval

New York: Subject to WCB guidelines, typically based on complexity

Pennsylvania: Maximum 20% of benefits

Georgia: Maximum 25% of income benefits (O.C.G.A. § 34-9-108)

Florida: Sliding scale: 20% of first $5,000, 15% of next $5,000, 5-10% of remainder

[YOUR STATE]: [INSERT LIMIT]

PART 6: SERVICES RENDERED

6.1 Summary of Legal Services

[// GUIDANCE: Describe the services provided to justify the fee]

Services Performed:

☐ Initial client consultation and case evaluation
☐ Gathering and review of medical records
☐ Filing of Application for Adjudication
☐ Written discovery (interrogatories, document requests)
☐ Deposition of applicant preparation
☐ Deposition of QME/AME
☐ Deposition of other witnesses: [LIST]
☐ Medical-legal evaluation coordination
☐ Mandatory Settlement Conference(s)
☐ Trial preparation
☐ Trial appearance
☐ Settlement negotiations
☐ Compromise and Release preparation
☐ Stipulations with Request for Award preparation
☐ Petition for Reconsideration
☐ Appeals
☐ Other: [SPECIFY]

6.2 Time Invested

Estimated Attorney Hours: [HOURS]

Estimated Paralegal/Staff Hours: [HOURS]

Total Hours Invested: [HOURS]

[// GUIDANCE: Time records may be requested by the judge to evaluate reasonableness]

6.3 Case Complexity

Factors Demonstrating Complexity:

☐ Multiple body parts claimed
☐ Contested compensability (AOE/COE dispute)
☐ Complex medical issues
☐ Apportionment dispute
☐ Multiple defendants/carriers
☐ Third-party case coordination
☐ Lien disputes
☐ Death benefits claim
☐ Appeal/Petition for Reconsideration
☐ Other: [SPECIFY]

6.4 Results Achieved

Outcome Summary:

[DESCRIBE THE FAVORABLE OUTCOME ACHIEVED FOR THE CLIENT]

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

PART 7: LITIGATION COSTS AND EXPENSES

7.1 Costs Incurred

[// GUIDANCE: List litigation costs separate from attorney fees]

7.2 Payment of Costs

Costs to be paid by:
☐ Deducted from client's recovery
☐ Paid by defendant as part of settlement
☐ Advanced by attorney (seeking reimbursement)
☐ Other arrangement: [SPECIFY]

PART 8: CLIENT CONSENT

8.1 Client Acknowledgment

Applicant acknowledges and agrees:

☐ I have reviewed and understand the fee agreement with my attorney.

☐ I understand that attorney fees of $[AMOUNT] ([___]%) will be deducted from my benefits.

☐ I believe the fee is fair and reasonable for the services provided.

☐ I consent to the payment of this fee to my attorney.

☐ I understand that the fee must be approved by the Workers' Compensation Judge.

Applicant Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

PART 9: REASONABLENESS FACTORS

9.1 Factors Supporting Reasonableness

[// GUIDANCE: The judge considers various factors in determining whether the fee is reasonable]

The requested fee is reasonable considering:

☐ Time and labor required - [HOURS] hours invested over [DURATION]

☐ Novelty and difficulty - Case involved: [DESCRIBE CHALLENGES]

☐ Skill required - Specialized knowledge in: [AREAS]

☐ Preclusion of other employment - Case required substantial time commitment

☐ Customary fee - [___]% is customary in this jurisdiction

☐ Results obtained - $[AMOUNT] in benefits secured

☐ Experience and reputation - Attorney has [YEARS] years of workers' comp experience

☐ Nature of fee - Contingency fee means attorney assumed risk of non-payment

☐ Time limitations - Case required expedited attention due to: [EXPLAIN]

☐ Relationship with client - [DESCRIBE IF RELEVANT]

PART 10: COMPARISON TO STATUTORY STANDARDS

10.1 Compliance with State Requirements

This fee request complies with [STATE] law because:

☐ The fee does not exceed the statutory maximum of [___]%

☐ The fee is calculated only on benefits subject to attorney fees

☐ The fee is supported by a written fee agreement

☐ The fee is reasonable considering the factors above

☐ Other compliance factors: [SPECIFY]

10.2 Deviation Request (if applicable)

☐ Not applicable - Fee is within standard limits

☐ Deviation requested - Attorney requests approval of fee exceeding standard rates because:

[EXPLAIN EXTRAORDINARY CIRCUMSTANCES JUSTIFYING HIGHER FEE]

____________________________________________________________________________

____________________________________________________________________________

PART 11: PAYMENT INSTRUCTIONS

11.1 Source of Fee Payment

The attorney fee shall be paid from:

☐ Permanent disability benefits
☐ Temporary disability benefits
☐ Settlement proceeds (C&R)
☐ Other: [SPECIFY]

11.2 Payment Method

☐ Deduction from periodic payments
Amount per payment: $[AMOUNT]
Duration: [NUMBER] payments

☐ Lump sum deduction from settlement
Gross settlement: $[AMOUNT]
Attorney fee: $[AMOUNT]
Costs: $[AMOUNT]
Net to applicant: $[AMOUNT]

☐ Direct payment by defendant
[DESCRIBE ARRANGEMENT]

11.3 Payee Information

Make Fee Payment To:
[ATTORNEY/FIRM NAME]
[ADDRESS]
Tax ID: [NUMBER]

PART 12: ATTORNEY DECLARATION

I, [ATTORNEY NAME], declare under penalty of perjury:

☐ I am the attorney of record for Applicant [APPLICANT NAME] in this matter.

☐ I have a written fee agreement with the Applicant, a copy of which is attached.

☐ The services described in this petition were actually performed.

☐ The fee requested is in accordance with the fee agreement and applicable law.

☐ The fee requested is fair and reasonable for the services rendered and results obtained.

☐ I have explained this fee petition to my client, who consents to the fee.

☐ All information in this petition is true and correct.

Attorney Signature: _________________________________

Printed Name: [NAME]

State Bar Number: [NUMBER]

Date: [DATE]

PART 13: ORDER APPROVING ATTORNEY FEE

FOR WORKERS' COMPENSATION JUDGE USE ONLY

CASE NUMBER: [NUMBER]

APPLICANT: [NAME]

DEFENDANTS: [NAMES]

Having considered the Petition for Approval of Attorney's Fees:

☐ FEE APPROVED AS REQUESTED

Attorney fee of $[AMOUNT] ([___]%) is approved.

☐ FEE APPROVED IN MODIFIED AMOUNT

Attorney fee of $[AMOUNT] ([___]%) is approved.

Reason for modification:
____________________________________________________________________________

☐ FEE DENIED

Reason:
____________________________________________________________________________

Payment Instructions:
____________________________________________________________________________

IT IS SO ORDERED.

Workers' Compensation Judge: _________________________________

Printed Name: Hon. [NAME]

Date: [DATE]

PART 14: PROOF OF SERVICE

I declare that on [DATE], I served a true copy of this Petition for Approval of Attorney's Fees on:

Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

PART 15: ATTACHMENTS

☐ Attorney-Client Fee Agreement
☐ Settlement documents (C&R or Stips)
☐ Itemized statement of services (if requested)
☐ Time records (if requested)
☐ Client consent form
☐ Benefits calculation worksheet
☐ Other: [SPECIFY]

[END OF DOCUMENT]