Can the form be e-signed?

Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retained records are satisfied. Confirm any agency-specific e-sign rules before submitting.

Is notarization required?

Generally not for DWC Form 3; most attorney fee disclosures are filed without a notary. However, if a signature needs to be independently verified or a local rule requires notarization, follow the clerk's instructions.

What if information changes?

Submit an amended DWC Form 3 or a supplemental disclosure as soon as practicable. Clearly describe changes, attach revised invoices or corrected calculations, and date the amendment. Timely updates reduce disputes and support administrative review.

The attorney of record must sign and date the disclosure. The claimant should sign any client authorization or acknowledgment fields. If multiple counsel are titled, each counsel should sign where their fees are disclosed.

Which supporting documents to attach

Attach retention or contingency agreements, itemized billing ledgers with dates and rates, copies of invoices, and settlement worksheets. Where expenses are claimed, include receipts. Omitting attachments commonly results in requests for supplemental documentation.

Can I e-submit to the DWC?

E-submission options vary by regional DWC office and case type. Some clerks accept emailed PDFs or portal uploads while others require physical filing or in-person submissions. Confirm electronic filing procedures with the assigned clerk or local DWC office before sending.

Electronic Signature
Templates
Other
DWC Form 3 Attorney Fee Disclosure Statement

DWC Form 3 Attorney Fee Disclosure Statement

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

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:

Anaheim - AHM

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

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.

I hereby declare under penalty of perjury that I am the attorney representing the above-named employee, or am an attorney licensed by the State Bar of California regularly employed by the firm by which the employee will 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.

DWC Form 3 (Rev. 1/17)

Overview of the DWC Form 3 Attorney Fee Disclosure Statement

The DWC Form 3 Attorney Fee Disclosure Statement is a California Division of Workers' Compensation form used to disclose attorney fees in workers' compensation settlements and awards. It records the attorney's identity, the fee arrangement, itemized charges, and any contingent or hourly components so judges and claims administrators can evaluate fee reasonableness. The form supports transparent settlements, protects claimants from undisclosed charges, and creates a record for court review or administrative audit. Use of the form is routine in settlement approvals and fee petitions within the California workers' compensation system.

Why accurate fee disclosure matters

Completing the DWC Form 3 ensures transparent disclosure of attorney compensation, aids administrative review, and reduces disputes over fees. Proper disclosure protects claimants, supports court approval of settlements, and creates a clear record for audits and any subsequent fee challenges.

Who prepares and relies on this form

This form is typically prepared by attorneys representing injured workers and used by stakeholders during settlement and fee review.

Workers' compensation attorneys who represent claimants and prepare settlement documents.
Claimants reviewing fee allocations to confirm legal charges and net recovery amounts.
Employers, insurers, and administrative law judges assessing fee reasonableness and approval.

Stepwise process to prepare and submit the form

Follow these sequential steps to prepare, review, and submit the DWC Form 3 correctly for settlement or fee petition processing.

01

Gather Documents: Collect fee agreements, invoices, and supporting receipts.
02

Complete Form: Enter attorney and fee details accurately.
03

Attach Evidence: Include billing ledgers and retention agreement copies.
04

File or Submit: Provide form to DWC clerk or hearing officer.

Security and compliance considerations

Encryption: TLS 1.2/1.3 in transit

At-rest: AES-256 encryption at rest

Certifications: SOC 2 Type II, ISO 27001

HIPAA: BAA available for covered entities

Compliance: ESIGN and UETA compliant

Accessibility: WCAG 2.0 Level AA

Potential risks and consequences of errors

Invalid Disclosure: May void fee approval

Late Filing: Could delay settlement

Missing Receipts: Triggers supplemental requests

TIN Errors: Backup withholding risk

Incorrect Amounts: May prompt review

Intentional Misreporting: Possible sanctions

Common preparation pitfalls to avoid

Incomplete calculations that omit contingency adjustments or misapply hourly rates lead to incorrect totals and frequent requests for clarification.
Failing to attach itemized billing ledgers and expense receipts commonly results in administrative delays and supplemental disclosure orders.
Using inconsistent names or addresses between the form, retainer, and court filings can cause identity verification problems.
Relying solely on handwritten calculations without showing supporting arithmetic invites challenges and slows judicial review.

Essential elements to include on the form

Essential parts of a properly completed DWC Form 3 include clear fee breakdowns, party identification, supporting exhibits, and signature blocks to satisfy administrative review and protect claimant interests.

Attorney Info

Provide attorney name, bar number, firm address, phone, and email. Accurate contact details enable timely clerk communication and ensure proper attribution if fee disputes arise.

Fee Terms

Describe hourly, flat, or contingency terms; include percentages, caps, and any conditional adjustments. Clarity on fee mechanics reduces later disputes and supports reasonableness determinations procedures.

Itemized Fees

Show line-item calculations: hours, rates, lodestar computations, multiplier justifications, and total. Include dates for each entry and explanatory notes where needed to support billing validity.

Costs

Separate recoverable costs from attorney compensation. Provide invoices and proof of payment for third-party expenses, photocopying, medical records retrieval, and expert witness fees where applicable.

Signatures

Include dated signatures for attorney and client where required. Where multiple counsel represent the claimant, ensure each signing counsel's fee share is clearly documented beside their signature.

Attachments

Attach retention agreement, billing ledger, settlement worksheet, and any court or administrative orders. Label exhibits and reference them within the form's explanation fields for fast review.

Configuring an online workflow for the form

Configure an online workflow for e-preparation, signature routing, and secure submission using standard field mappings and conditional steps.

Field	Configuration
Upload document	PDF, DOCX supported
Configure fields	Place signature, date, and initial fields
Signer authentication	Email and SMS code options
Submission method	Portal upload or print-and-file

Technical requirements and integration notes

Platforms and integrations support secure e-signature workflows and document storage for DWC Form 3 processing.

Formats: PDF, DOCX, and image files
Integrations: Salesforce, NetSuite, Google Workspace
Authentication: Email, SMS code, OAuth options

Timing considerations and common deadlines

Key timing considerations for preparing and filing the DWC Form 3 follow typical settlement schedules and administrative review cycles.

Submit prior to settlement approval:

Provide completed disclosure with settlement documents

When filing a fee petition:

Attach form to the petition for ALJ review

If fee terms change during processing:

File an amended disclosure promptly

At least five business days before hearing:

Confirm clerk's local rules for timing

Retention begins at filing date:

Keep originals for statutory retention

Key milestones from preparation to administrative decision

Milestones below reflect sequential steps from preparation through administrative approval for fee disclosure and settlement processing.

01

Prepare form

Assemble fees, invoices, and authorization

02

Review internally

Attorney and client confirm contents

03

File with DWC

Submit to clerk or via electronic portal

04

Administrative decision

ALJ or clerk issues approval or questions

How the DWC Form 3 differs from a settlement fee clause

How the DWC Form 3 compares with a settlement agreement fee clause in scope, filing, and enforceability is summarized below.

Criteria	DWC Form 3	Settlement Clause
Requires disclosure		often included
Notarization required		rare
Filed with agency
Binding on court	administrative	contractual

Basic pricing and feature comparison for common e-sign vendors

Compare core pricing and feature basics for common e-sign vendors relevant to preparing and e-signing the DWC Form 3.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Real-world examples showing good disclosure practice

Real examples illustrate how accurate fee disclosures prevent delays and support administrative approvals in workers' compensation settlements.

Attorney example

An attorney filed a complete DWC Form 3 with itemized lodestar calculations and attached invoices prior to settlement approval, expediting clerk review.

The clerk issued approval without supplemental requests.
Clear documentation reduced administrative back-and-forth, allowed the hearing officer to approve fees promptly, and enabled the claimant to receive net proceeds without delay; the record provided full transparency for any future audit or review.

Insurer example

An insurer reconciled payments with disclosed attorney fees and lien offsets, calculating claimant net recovery before final disbursement to avoid post-settlement disputes.

All figures were reconciled pre-disbursement.
This practice reduced clawback risk, simplified internal accounting, and provided a clear audit trail for the insurer and claimant; detailed exhibits allowed auditors to verify amounts without lengthy document requests.

Practical tips to reduce delays and scrutiny

Best practices focus on completeness, standardized formats, corroborating evidence, and timely amendments to prevent administrative delays during fee review.

Always use consistent legal names

Ensure the attorney and claimant names match retainer agreements, billing records, and court filings. Discrepancies cause verification delays and can trigger requests for corrective affidavits or supplemental disclosures from parties.

Attach itemized invoices and receipts

Provide dated invoices, billing ledgers, and receipts for all claimed expenses. Label exhibits clearly and reference them in the form to streamline clerk review and reduce follow-up requests for substantiation.

Always use MM/DD/YYYY for all dates

Enter all dates in MM/DD/YYYY format consistently across the form and attachments. Consistent dating prevents clerical confusion and simplifies chronological review during administrative or appellate scrutiny processes and storage requirements.

Confirm e-sign compliance and consent requirements

If using electronic signatures, provide ESIGN-consumer disclosure where applicable, record consent, and ensure authentication methods meet agency expectations. Keep an auditable trail showing intent, attribution, and a retained copy of the signed record.

Primary signers and reviewers

Claimant's Attorney

A claimant's attorney prepares the DWC Form 3 to disclose fees, attach billing records, and certify that fee allocations comply with retainer terms and statutory reasonableness standards. They ensure documentation supports the requested fee.

Claims Administrator

A claims administrator or insurer reviews the disclosure to reconcile payments, verify lien reductions or subrogation offsets, and calculate net claimant recovery, using the form to confirm that fee items align with recorded invoices and payment histories.

Common questions and answers

Common questions and answers about completing, signing, and submitting the DWC Form 3 appear below to resolve frequent issues.

Need help? Contact support

Can the form be e-signed?
Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retained records are satisfied. Confirm any agency-specific e-sign rules before submitting.
Is notarization required?
Generally not for DWC Form 3; most attorney fee disclosures are filed without a notary. However, if a signature needs to be independently verified or a local rule requires notarization, follow the clerk's instructions.
What if information changes?
Submit an amended DWC Form 3 or a supplemental disclosure as soon as practicable. Clearly describe changes, attach revised invoices or corrected calculations, and date the amendment. Timely updates reduce disputes and support administrative review.
Who signs the form?
The attorney of record must sign and date the disclosure. The claimant should sign any client authorization or acknowledgment fields. If multiple counsel are titled, each counsel should sign where their fees are disclosed.
Which supporting documents to attach
Attach retention or contingency agreements, itemized billing ledgers with dates and rates, copies of invoices, and settlement worksheets. Where expenses are claimed, include receipts. Omitting attachments commonly results in requests for supplemental documentation.
Can I e-submit to the DWC?
E-submission options vary by regional DWC office and case type. Some clerks accept emailed PDFs or portal uploads while others require physical filing or in-person submissions. Confirm electronic filing procedures with the assigned clerk or local DWC office before sending.

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