Fill and Sign the State Ex Rel Workerscomp V Brown 805 P2d 830 Form

WORKER'S COMPENSATION REPRESENTATION AGREEMENT 1. FOR AND IN CONSIDERATION of legal services rendered and to be rendered, I, _________________________________________________________, (Claimant) do hereby employ ______________________, (Attorney) to represent Claimant in a Worker's Compensation claim to be filed with the Mississippi Worker's Compensation Commission, (MWCC) against ___________________________ (Employer), and __________________________________ (Carrier), for compensation and medical treatment for disabilities resulting from ____________________________________________________________________________________________________________________________ that occurred on or about the _______ day of _______________________, 19______ and arising out of my employment, and also for any penalties and interest arising out of said claim which may be allowed by law;2. I hereby agree to pay Attorney an attorney's fee equal to twenty-five (25%) per cent of the total award of compensation, including penalties and interest, for legal services performed by Attorney before the MWCC, in accordance with the applicable laws, and subject to approval by the MWCC;3. All necessary costs and expenses in the prosecution of the case shall be the responsibility of the Claimant. All expenses and charges of any nature made by the Attorney in conjunction with the case will be paid by Claimant. If Attorney advances funds on behalf of the Claimant for any costs or expenses, Claimant agrees to reimburse Attorney for such advancements. In the event of a recovery, Claimant agrees that Attorney will pay any of these unpaid bills from Claimant's share of the recovery. If Claimant recovers nothing, it is understood that Attorney is not bound to pay any of these expenses. 4. Attorney, in his absolute discretion may withdraw at any time from the case upon notice to Claimant if investigation discloses no basis for further action on behalf of Claimant, or if there is no insurance coverage. Associate counsel may be employed at the discretion and expense of Attorney. 5. Claimant agrees not to compromise the claim without the Attorney's consent and Attorney is not authorized to do so without the consent of the Claimant. 6. The fee for services rendered by Attorney does not include the perfecting of an appeal on behalf of the Claimant or the representation of the Claimant if an appeal has been perfected by the adverse party. If either the Claimant, or the Employer/Carrier, prosecute an appeal from the Order of the MWCC to the Circuit Court or Supreme Court, then an additional attorney's fee will be required, and Claimant hereby agrees, in the event of an appeal, to pay Attorney an attorney's fee equal to thirty-three and one-third (33 1 / 3%) per cent of the total award of compensation, including penalties and interest, for legal services performed in prosecuting the claim.WITNESS MY SIGNATURE this the ________ day of _________________________________ 2019.____________________________________________________CLAIMANT EMPLOYMENT ACCEPTED ON THE ABOVE TERMS BY_____________:____________________________________________________