Appendix 5B - Claimant's Attorney Memorandum

CLAIMANT’S ATTORNEY MEMORANDUM

I. CLAIM INFORMATION CLAIMANT: EMPLOYER: IC# (primary): SURETY: DOB: Date of Accident/Injury (Primary): TPA/Claim Administrator: Date of Manifestation of Occ Disease: Nature of Injury or OD: CLAIMANT ATTORNEY: Phone #: Date Retained: Retainer Agreement and Disclosure Statement Attached? No Yes DEFENDANT ATTORNEY: Future Medical to remain open after settlement? No Yes If right to future medical is resolved by settlement, have you considered Medicare’s interest as a secondary payor? See, 42 U.S.C. § 1395y(b)(2). No Yes Issues undisputed at time of retention of Claimant’s Attorney: Dollar value of same: Disputes resolved by settlement (succinct bullet points): Non-Medical factors (Brief narrative, to include current employment status): Permanent Limitations / Restrictions (list the final given by each med provider): II. ATTORNEY FEES AND COSTS – PRIOR TO LUMP SUM SETTLEMENT A. Were Attorney fees taken on benefits paid prior to date of LSS execution? No Yes If so, identify all benefits from which past fees were taken and describe what you did to “primarily or substantiallyâ€� secure the same. Benefit type $ Amount Date from Date to Brief narrative describing what you did to secure this benefit Amt of fee Supporting docs attch’d? B. Were Costs taken on benefits paid prior to date of LSS execution? yes If so, itemize the same: Nature of Services/product $ Amt III. ATTORNEY FEES AND COSTS – PROPOSED A. Gross amount payable to claimant on approval of LSS $ B. The amount of the fund secured primarily or substantially out of which the attorney seeks to be paid $ C. Proposed attorney fee payable on approval of LSS $ Page 1 of 2 – Appendix 5B

D. What did counsel do to “primarily or substantially� secure the fund from which fees will be taken? (brief narrative) E. Additional costs to be paid from settlement proceeds: Nature of Services/product $ Amt IV. DISPUTED MEDICALS Are there any disputed past medical bills, responsibility for which is resolved by this settlement? No Yes If so, itemize and describe treatment proposed for same in the table below: Provider Paid by 3rd party with claim of subrogation? $ Amt of invoiced bill, or, if “Yes� to prior, amt actually paid by 3rd party. If “Yes�, name of 3rd party. Compromised amount payable Who will pay? No Yes No Yes No Yes If Claimant is to pay disputed/unpaid medical bills to the provider, has the Claimant been counseled about possible consequences of not doing so? No Yes Has each subrogated 3rd party payor been contacted concerning the satisfaction of its contractual right of subrogation? No Yes None If “Yes�, describe the outcome: V. 72-802 ISSUES Does any creditor assert a claim against the settlement, or has any prior assignment of the settlement been made? No Yes If so, describe nature of alleged claim, and attach copy of the contract. VI. ADDITIONAL EXPLANATION, IF REQUIRED: Idaho Industrial Commission, Rev. 2014-02-04 Mail as .pdf to: AttorneyFeeMemo@iic.idaho.gov Page 2 of 2 – Appendix 5B