Notice of Legal Representation {SFN 12410}

NOTICE OF LEGAL REPRESENTATION LEGAL DIVISION SFN 12410 (07/2014) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com BEFORE WORKFORCE SAFETY & INSURANCE In the Matter of the Claim of ) ) ) ) ) ) ) Page 1 of 2 Claim No. for compensation from Workforce Safety & Insurance. NOTICE OF LEGAL REPRESENTATION I, the firm of , Attorney at Law, with whose address is . I am licensed to practice law in the State of North Dakota. I have been engaged by the injured worker in a claim against Workforce Safety & Insurance. I agree that I will follow the guidelines of Workforce Safety & Insurance (WSI) on payment of attorney fees and costs in my representation of the injured worker and submit monthly time statements to WSI to support my request for payment in accordance with N.D.A.C. §§ 92-01-02-11.1 and 92-01-02-11.2. Date Attorney for injured worker 1 American LegalNet, Inc. www.FormsWorkFlow.com NOTICE OF LEGAL REPRESENTATION LEGAL DIVISION SFN 12410 (07/2014) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE NUMBER (701) 328-3800 TOLL FREE FAX NUMBER 1-888-786-8695 TDD NUMBER (for the hearing impaired only) (701) 328-3786 www.WorkforceSafety.com Page 2 of 2 Acknowledgement of Legal Representation And Release (To be executed by Injured Worker) _______________________________ represents me before WSI, with full authority to (Name of attorney) execute instruments in my name, receive medical and other reports concerning my claim, and to do all things reasonable and necessary to adjudicate my claim before WSI, effective the date listed below. This document shall remain in effect for five years from the date of this notice or until revoked by me in writing, whichever occurs first. I revoke representation of any attorney previously representing me in connection with this workers' compensation claim. Date Injured Worker Claim Number Subscribed and sworn to before me this day of , 20 . Notary Public 2 American LegalNet, Inc. www.FormsWorkFlow.com