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WORKER'S COMPENSATION FEE AGREEMENT - Indiana Worker Compensation

VIEWS: 11 PAGES: 3

									                          WORKER'S COMPENSATION FEE AGREEMENT


        WHEREAS, ______________________________________ has suffered work related injuries as a
result of an accident which occurred at __________________________________ on
(date)________________________, he/she hereby appoints and declares RANDAL M. KLEZMER to be
his/her sole and only attorney to prosecute his/her cause of action, if any he/she has.

       HE/SHE FURTHER WARRANTS, covenants and contracts not to settle, compromise or negotiate a
settlement without the advice and consent of RANDAL M. KLEZMER, his/her attorney.

         IT IS FURTHER AGREED between the parties that there will be no attorney's fee if a recovery is not
affected, but that said attorney shall be entitled to, and shall be paid, a sum equal to $100.00 plus 20% of the
first $10,000.00, 15% of the second $10,000.00 and 10% of the balance, if any, of all monies recovered upon
the settlement of said worker compensation claims prior to the commencement of a lawsuit for the collection
thereof. Said attorney shall be entitled to, and shall be paid a sum equal to an amount as determined by the
Worker's Compensation Board. Such attorney's fees shall be deducted from the total recovery prior to
reimbursement from such recovery to said attorney for their direct out-of-pocket expenses advanced in the
client's behalf. Client further agrees to be responsible for repaying upon demand the law firm cost incurred
in this matter. Such costs include, but are not limited to, mileage to and from out of county hearings,
depositions, conferences and investigations; long distance telephone calls at $1.00 per call, postage, copies,
court reporter fees, professional reports, and independent medical exam fees. These costs will be billed as
they are incurred and are due upon receipt. The law firm reserves the right to request pre-payment of such
costs as a pre-requisite of continued representation.

        IT IS FURTHER AGREED that client shall inform attorney of his/her current address and telephone
number. In the event that the attorney does not have the current address and telephone number of client and
the attorney cannot locate the current whereabouts of client, attorney may withdraw from this representation
without notice to client due to attorney’s inability to locate client.

        SAID ATTORNEY reserves the right to withdraw from this representation, upon determination that
a proposed settlement offer, declined by client, should be accepted, or that, in attorney's judgment, a recovery
of adequate amount to justify continued pursuit of the claim cannot be made. If client terminates the
attorney-client relationship, client understands that the attorney may request an attorney fee at the attorney’s
hourly rate of One Hundred Fifty Dollars ($150.00), but under no circumstance will the attorney request
attorney fees greater than that allowed by the Indiana Worker’s Compensation Act.

        THE UNDERSIGNED HEREBY GUARANTEES all indebtedness incurred herein, and in the event
this account is turned over for collection, shall be responsible for all costs incurred, including but not limited
to reasonable attorney fees.

        Dated this ________ day of ____________________________, 2002.



________________________________                        ___________________________________
RANDAL M. KLEZMER                                       CLIENT
                                     EPSTEIN & FRISCH
                                       200 Jefferson Plaza
                                      One Virginia Avenue
                                   Indianapolis, Indiana 46204


TO:                                                   PATIENT:

                                                      DOB:

                                                      SSN:

                                                      ADDRESS:


                                                      DATE INJURED:

                                MEDICAL AUTHORIZATION

         I hereby request and authorize all doctors, nurses, technicians and hospitals, if requested by
EPSTEIN & FRISCH, Attorneys, to furnish my said attorneys or anyone designated in writing by them, all
medical and psychiatric records and reports, including x-rays and photostatic copies, abstracts or excerpts of
all records and any other information they may request relating to any examination, treatment or opinion
concerning any condition that I or any of my children may have had in the past, now have or may have in the
future. The information requested is necessary to pursue an injury case my attorneys are handling. A copy
of this authorization shall be the same as the original.


                      REVOCATION OF ALL PRIOR AUTHORIZATIONS

        I hereby completely revoke all previous authorizations given by me for the release of medical
information for any reason or purpose whatsoever, and do specifically request that no medical information of
any nature be given out at any time to any insurance company, its attorneys or anyone else other than one of
my treating doctors and EPSTEIN & FRISCH, my attorneys, or someone designated in writing by my
attorneys. I understand that I may revoke this authorization at any time in writing.


                    AUTHORIZATION TO PAY UNPAID MEDICAL BILLS

        I hereby direct and authorize EPSTEIN & FRISCH, out of any sums received by them to which I may
be entitled, to pay all unpaid medical bills that you have presented to them prior to the time of the
distribution of any proceeds to me.


DATE:
                                                      Signature


Witness
                                     EPSTEIN & FRISCH
                                       200 Jefferson Plaza
                                      One Virginia Avenue
                                   Indianapolis, Indiana 46204


TO:                                                  EMPLOYEE:

                                                     DOB:

                                                     SSN:

                                                     ADDRESS:


                                                     DATE INJURED:


                           AUTHORIZATION FOR RELEASE OF
                             EMPLOYMENT INFORMATION


       The law office of EPSTEIN & FRISCH represent the undersigned in a claim for personal injuries. It
will be necessary for them to obtain employment information from my employers, past and present,
concerning my earnings, employment record, and personnel file. I hereby request and authorize all such
employers or their representatives to furnish my attorneys any and all records, reports, or information they
may request relating to such matters.

     I HEREBY REVOKE ANY SUCH PREVIOUS AUTHORIZATIONS GIVEN BY ME FOR THE
RELEASE OF SUCH INFORMATION, AND REQUEST THAT NO INFORMATION OF ANY SUCH
NATURE BE GIVEN TO ANY INSURANCE COMPANY OR OTHER PERSON OTHER THAN MY
ATTORNEYS.




DATE:_______________________                 _________________________________________
                                             Signature


____________________________________
Witness

								
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