Kentucky > Workers Comp
Statement Of Proposed Stipulations And Notice Of Contested Issues (Hearing Loss) - Kentucky
| Statement Of Proposed Stipulations And Notice Of Contested Issues (Hearing Loss) Form. This is a Kentucky form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
H.L. COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS CLAIMS CLAIM NO(S). _____________________ BEFORE ALJ __________________________ _____________________________________________ PLAINTIFF VS. _____________________________________________ _____________________________________________ DEFENDANT(S) STATEMENT OF PROPOSED STIPULATIONS AND NOTICE OF CONTESTED ISSUES * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * I. STIPULATIONS 1. Coverage under the Act. 2. The employer had due and timely notice of the employees claim. 3. Employees average weekly wage. 4. Employees last date of exposure to industrial noise: ________________________________ 5. Employees was last exposed while employed by this employer. 6. Employee was exposed to industrial noise for _______ years while employed by this employer. 7. Employees date of birth: _____________________________________________________ 8. Employees educational level: ________________________________________________ 9. Employees specialized or vocational training: _____________________________________ 10. The following medical expenses are in dispute: Medical provider Service Date Amount Nature of Dispute 11. Other matters: ___________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ <<<<<<<<<********>>>>>>>>>>>>> 2 II. CONTESTED ISSUES The following issues are contested: 1. ___________________________________________________________________________ 2. ___________________________________________________________________________ 3. ___________________________________________________________________________ 4. ___________________________________________________________________________ 5. ___________________________________________________________________________ III. DESIGNATION OF EVIDENCE IN BENEFIT REVIEW RECORD The following evidence in the benefit review record is designated for consideration by the Administrative Law Judge: 1. ______________________________________________________________________ 2. ______________________________________________________________________ 3. ______________________________________________________________________ 4. ______________________________________________________________________ 5. ______________________________________________________________________ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PLEASE NOTE: 1. All matters not in controversy should be stipulated. 2. The issues listed above will be considered by the Administrative Law Judge. This the _______ day of ______________________________, 200___. __________________________________________ Attorney Revised: 12/12/01
|
|||||||
