Form 109 "Standard Form for Attorney Fee Election" - Kentucky

What Is Form 109?

This is a legal form that was released by the Kentucky Department of Workers' Claims - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Kentucky Department of Workers' Claims;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 109 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Workers' Claims.

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Download Form 109 "Standard Form for Attorney Fee Election" - Kentucky

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Form 109
Attorney Fee Election
Adopted March 15, 1995
 
DEPARTMENT OF WORKERS CLAIMS
FRANKFORT, KENTUCKY 40601
 
 
 
State's File Number:
STANDARD FORM FOR
Carrier For:
 
ATTORNEY FEE ELECTION
Employer:
 
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
day of
, 20
.
 
 
 
 
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
Form 109
Attorney Fee Election
Adopted March 15, 1995
 
DEPARTMENT OF WORKERS CLAIMS
FRANKFORT, KENTUCKY 40601
 
 
 
State's File Number:
STANDARD FORM FOR
Carrier For:
 
ATTORNEY FEE ELECTION
Employer:
 
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
day of
, 20
.
 
 
 
 
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