Application for Attorney Fees

APPLICATION FOR ATTORNEY FEES (DWC Form-152)

DWC152 (Rev. 11/17)

Online submission available through Web-Enabled Attorney Fee Processing System at: https://txapps.texas.gov/NASApp/twcc/TwccAFManager

I. GENERAL INFORMATION

1. DWC Claim Number   2. Dates of Service From To

3. Indicate if benefit percentage being requested is less than 25%.

4. Are any fees for dispute where claimant prevailed on entitlement to or amount of supplemental income benefits (SIBs)?* Yes No

5. Attorney 1 - Name (Last, First, MI)   6. Attorney 1 - Bar Card Number

7. Firm Name   8. Firm Mailing Address (Street or PO Box, City, State, ZIP)

9. Firm Phone Number   10. Attorney represents: Employee Insurance Carrier Beneficiary

11. Attorney 2 – Name (Last, First, MI)   12. Attorney 2 - Bar Card Number

13. Attorney 3 – Name (Last, First, MI)   14. Attorney 3 - Bar Card Number

15. Injured Employee’s Name (Last, First, MI)   16. Date of Injury

17. Beneficiary’s Name (if applicable)   18. Beneficiary’s SSN (if applicable)

19. Beneficiary’s Address (Street or PO Box, City, State, ZIP) (if applicable)

20. Beneficiary Type: Spouse Common Law Spouse Parent Step-parent Grandchild Grandparent Child Sibling Other

*If "Yes," only the fees and expenses related to the Supplemental Income Benefits (SIBs) issue may be included on this application. Any fees or expenses not related to the SIBs issue, including fees related to SIBs matters not at issue in the dispute proceeding, must be included on a separate DWC Form-152.

II. REQUEST SUMMARY

21. Provide the information requested below. Use the Attorney Services chart in Section III to total the hours for each attorney/legal assistant. Provide hourly rates and calculate the dollar amount for each attorney or legal assistant’s time.

III. ATTORNEY SERVICES (Attach additional pages as necessary.)

22. Provide the information requested in the chart below. Use the Table of Codes on page 3 as appropriate. Report time as whole hours and decimal fractions of hours (e.g. 1 hour 6 minutes = 01.1). If request exceeds guidelines in 28 Texas Administrative Code (TAC) §152.4, attach written justification.

IV. ATTORNEY EXPENSES (Attach additional pages as necessary.)

23. Provide the information requested below.

V. CERTIFICATION

24. I certify the following:

• I am an attorney for the client identified in this application.
• Regardless of the method used to submit this application (original signature, stamp signature, encryption or facsimile), it shall have the same effect as submission with an original signature.
• I am duly authorized and qualified in all respects to make this application.
• I am responsible and liable for any information contained in this submission.
• I have read this application and any attached document(s).
• Every statement, numerical figure and calculation contained herein is within my personal knowledge, is true and correct, and represents services, charges, and expenses provided by me or a legal assistant under my supervision.

TABLE OF CODES

Category Codes

AL Appeals

AS Agreements and Settlements

BR Benefit Review Conference

CC Contested Case Hearing

CF Communications

IR Informal Resolution

IS Initial Services

TT Travel Time

Action Performed Codes

AD Attend Deposition of

AP Attend Proceeding

CF Complete and File Claim Form

DL Draft Letter to

DP Draft and File Pleadings/Documents

II Initial Interview

LR Performed Legal Research

OC Office Conference with

PP Prepare for Proceeding

RF Review File

RR Receive/Review Documents

SF Set Up File

TC Telephone Conference with

Recipient Codes

A Court Reporter

B Beneficiary

C Claimant

D Disability Determination Officer

E Employer

H Administrative Law Judge

I Carrier

J Adjuster

O Ombudsman

P Health Care Provider

R Benefit Review Officer

T Other Division Staff

W Witness

Z Other Carrier

Actor Codes

A1 Attorney 1 (primary attorney)

A2 Attorney 2 (secondary attorney)

A3 Attorney 3 (tertiary attorney)

LA Legal Assistant

IV. ATTORNEY EXPENSES (Expense Code List)

AF Air Fare

AR Auto Rental

CC LD Collect Call from Client

CR Court Reporter

IN Investigative Services

LR Legal Research

ML Meals

OO Other Overnight

PK Parking

RC Record Copies

SP Subpoena

TC LD Call from Client

TD Travel for BRC*

TE Travel for CCH*

TF Translator

TH LD Call to Health Provider

TP LD Call to Other Party

TR LD Call to Other Party’s Rep

WF Witness Fee

NOTE: LD = Long Distance

V. CERTIFICATION

I certify that the information provided is true and correct to the best of my knowledge.