BEFORE THE DIVISION OF WORKERS COMPENSATION

STATE OF KANSAS

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Claimant )
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VS. )
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Respondent ) Docket No.
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AND )
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Insurance Carrier )

STATEMENT REGARDING ATTORNEY FEES

I __________________________________________________________ represent the employee or the employee's dependents in

this claim and hereby certify that the following statements have been completed by me and are true and correct to the best of
my knowledge and belief:

1. My written contract of employment with the employee or the employee's dependents was entered into on the _________
day of ____________________, 20_______, and a true and correct copy thereof is attached hereto.

2. I claim attorney's fees in this claim in the total amount of $_____________________________, which is _________ percent
of the amount of compensation to be recovered and paid on behalf of the employee or the employee's dependents.

3. The following offers of settlement, and the dates thereof, were made by or on behalf of the employee or the employee's
dependents prior to the time that a settlement was agreed to among the parties: ______________________________________
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4. The following offers of settlement, and the dates thereof, were made by or on behalf of the respondent or insurance
carrier prior to a settlement having been agreed to among the parties: ______________________________________________
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5. Approximately __________ hours were expended by me in the course of the legal representation of the employee or the
employee's dependents.

K-WC 160 (Rev. 12-06)

6. The following novel or difficult legal or factual questions were involved in the legal representation of the employee or the
employee's dependents: __________________________________________________________________________________________
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7. The extent to which my acceptance of legal representation of the employee or the employee's dependents in this claim
precluded other employment, if such was apparent to the employee or the employee's dependents: _____________________
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8. The fee customarily charged in this locality for representation similar to my services rendered herein is: _______________
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9. The following time limitations were imposed in this claim by the employee, the employee's dependents or by the
circumstances involved: ______________________________________________________________________________________
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10. The following sets forth prior occasions upon which the employee or the employee's dependents have been represented by
me, the dates thereof, and the general nature of the representation involved: ___________________________________________
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11. I have been practicing workers compensation law for ________ years.

12. Representation of claimants, employers and insurance carriers in connection with workers compensation claims
constitutes ________ percent of my total practice as an attorney.

____________________________________________________________
Attorney for the Claimant