Fill and Sign the Get the Dwc Form 3 Attorney Fee Disclosure Statement Form

DWC Form 3 (Rev. 1/17) State of California Department of Industrial Relations Division of Workers' Compensation FEE DISCLOSURE STATEMENT If you choose to be represented by an attorney, your attorney's fees will be deducted from your benefits. The fee will be approved by the Workers' Compensation Appeals Board with consideration given to the: (1) responsibility assumed by the attorney; (2) care exercised in representing you; (3) time involved; and, (4) results obtained. Attorney's fees normally range from 9% to 12% of the benefits awarded. There are certain circumstances where your employer (or his/her insurer) may be liable to pay your attorney's fees. For example, if the employer disputes a permanent disability evaluation obtained when you were not represented by an attorney, your employer may be liable for any attorney fees you incur because of the dispute. If at any time you no longer wish to be represented by the attorney, you may withdraw from representation by notifying the attorney. If you withdraw from representation, the fee amount found by a workers' compensation judge to be the fair value of any work the attorney did in your case will be deducted from your award. Your case is being filed at the Division of Workers’ Compensation at the following location: The employee has been advised of the district office at which his or her case will be filed and that he or she may be required to attend conferences or hearings at this location at his or her own expense. An Information and Assistance Officer may be able to answer your questions concerning your workers' compensation benefits at no charge to you. The Officer may be able to resolve your problems without the need for litigation. Call this toll -free number: 1 -800- 736-7401 Employee's Signature Date _________________ Employee's Name I hereby declare under penalty of perjury that I am the attorney represent ing the above -named employee, or am an attorney licensed by the State Bar of California regularly employed by the firm by which the employee wi ll be represented , and have advised the employee of their rights as set forth above and in Labor Code section 4906(e) and (g)(1) . Attorney's Signature __________________________ Date _______________________ Attorney's name _____________________________ Address ______________________________________________________________________________ Phone No. ( ) Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying worker' compensation benefits or payments is guilty of a felony.