Reduction Request Form

Reduction Request Form

Exclusively for Attorneys
Instructions:
1. Complete the Form: Ensure all required fields are filled out accurately.
2. Attach Required Documents:
  1. A copy of the attorney/client fee agreement signed by the member.
  2. Include an itemized list of expenses incurred, if applicable.
  3. Add any supplemental attachments as needed.
3. Review and Confirmation:
  1. Ensure all information is correct before submission.
  2. You will receive a confirmation email once your request has been processed.
Section 1: Member Information
Member's First and Last Name

First NameLast Name
Alias
Member's UID
Date of Birth (DOB)

MonthDayYear
Date of Injury

MonthDayYear
Section 2: Settlement Details
Date of Settlement

MonthDayYear
Settlement Amount (in dollars)
Attorney's Fee (in dollars)
Section 3: Additional Information
Comments
Section 4: Attachments
Attachment Checklist:
Upload Attachments

The attorney/client fee agreement and itemized list of expenses incurred is required
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Feedback & Submission
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Confirmation Email
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Enter a valid email address in the confirmation email field above to receive a confirmation with a copy of your submission.
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Section 1: Member Information