Free For 109 - Kentucky

Form 109 Attorney Fee Election Adopted March 15, 1995

DEPARTMENT OF WORKERS CLAIMS FRANKFORT, KENTUCKY 40601

STANDARD FORM FOR

State's Number For:

File: Carrier: Employer:

ATTORNEY FEE ELECTION

Carrier's File No.

I hereby certify that my attorney has fully explained to me my options regarding the payment of attorney fees. I hereby select the following method: A. _____ I elect to pay my attorney's fee out of my personal funds. B. _____ I elect to have any attorney's fee paid in a lump sum and to have each of my weekly benefits equally reduced until the defendants have recouped the amount of my attorney's fee. C. _____ My case has been settled for a lump sum. I elect to pay my attorney's fee out of my lump sum settlement. , plaintiff herein, being duly sworn, states that the statement of the foregoing election is true.

Plaintiff SUBSCRIBED AND SWORN to before me this , 19 . day of

Notary Public or other authorized officer I hereby certify that I have fully explained the provisions of KRS 342.320 to my client.

Attorney for Plaintiff