Attorney Certification For No Liability Stipulations {WC-15}

WC-15 ATTORNEY CERTIFICATION FOR NO LIABILITY STIPULATIONS GEORGIA STATE BOARD OF WORKERS' COMPENSATION ATTORNEY CERTIFICATION FOR NO LIABILITY STIPULATIONS Board Claim No. Employ ee Last Name Employ ee First Name M.I. SSN or Board Tracking # Date of Injury As counsel of record for the employee in the above referenced claim(s), I, , hereby certify and affirm my claim for reimbursable expenses is in compliance with and permitted by Rule 1.8(e) of the Georgia Rules of Professional Conduct, Board Rule 108 and Board Rule 15 and that I am charging a fair and reasonable fee to my client whi ch does not exceed 25% as allowed by O.C.G.A. 34-9-108 and Board Rule 108 as they apply to the alleged accident date(s) of : This (Day) day of (Month) / (Year) . Address Print Name Signature Telephone Number City GA Bar Number State Zip Code IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF W ORKERS' COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19). WC-15 REVISION . 07/2011 15 ATTORNEY CERTIFICATION FOR NO LIABILITY STIPULATIONS American LegalNet, Inc. www.FormsWorkFlow.com