Fillable Printable Form Template
Fillable Printable Form Template
Form Template
IC-32-A
An Equal Opportunity Employer and Service Provider
Timely, impartial resolution to workers’ compensation appeals
OIC-3022 Rev. (04.16)
Instructions:
Use this form to request an advancement to pay attorney fees, only.
The completed application can be filed at any Industrial Commissio n offic e.
The undersigned attorney-at-law, duly authorized by the applicant to represent him/her in the above captioned industrial
claim, certifies that:
(1
)
I have rendered the following services for this claim which were necessary to obtain the award for which the
advancement to pay the fee is requested:
Date
Applicant Signature (required)
Address on application is new
(2) Should the Application for Lump Sum Payment, now under consideration, be granted, the applicant will not be liable
for an
y further fee with respect to continuing compensation, except where a later dispute would arise in this clai
m,
requ
iring my additional services.
(3) Should the Application for Lump Sum Payment include a request for reimbursement of expenses (not to exceed
$1,000.00), a copy of the bill has been included with the application.
Attorney’s Signature (required)
Date
I, the undersigned applicant, am making application for a lump sum advancement for payment of attorney fees in the amount
of $_____________. If the lump sum payment is granted by the Industrial Commission of Ohio, either wholly or in part, I
request and authorize the Bureau of Workers' Compensation or self-insuring employer to di stribute the lump sum payment
directly to the person or persons to whom payment is now due from me, pursuant to any Commission order. This payment
will result in a reduction of weekly benefits from my Permanent Total Permanent Partial Death Award.
I certify that the above facts on my application are true.
Applicant Information
Name Name
Address Address
City, State, Zip City, State, Zip
Employer’s Representative Information
Name Name
Applicant Representative Information
Telephone Fax Telephone Fax
Telephone Fax Telephone Fax
Rep ID# Rep ID#
Employer Information
Claim Number:
APPLICATION FOR LUMP SUM PAYMENT OF ATTORNEY FEES
