Kentucky > Workers Comp
Statement Of Proposed Stipulations And Notice Of Contested Issues (Injury) - Kentucky
| Statement Of Proposed Stipulations And Notice Of Contested Issues (Injury) Form. This is a Kentucky form and can be used in Workers Comp . |
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INJURY 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. An employment relationship existed between the employee and employer at all relevant times. 3. Employee sustained a work-related injury(ies) on ____________________________________ 4. The employer received due and timely notice of employees injury(ies). 5. Employees average weekly wage. 6. Temporary total disability benefits were paid at the rate of $___________ per week from _____________________ through _______________________, for a total of $___________. 7. The employer has paid a total of $___________ for medical expenses as a result of this injury. 8. The following medical expenses are in dispute: Medical provider Service Date Amount Nature of Dispute 9. Employee _______ has _______ has not returned to work. 10. Employees current weekly wage is $_____________________________________________ 11. Employee _______ does _______ does not retain physical capacity to perform the type of work he did at date of injury. 12. Employees date of birth: _____________________________________________________ <<<<<<<<<********>>>>>>>>>>>>> 213. Employees educational level: ________________________________________________ 14. Employees specialized or vocational training: _____________________________________ 15. Other matters: ___________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ II. CONTESTED ISSUES The following issues are contested: 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
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