Kentucky > Workers Comp
Statement Of Proposed Stipulations And Notice Of Contested Issues (Occupational Disease) - Kentucky
| Statement Of Proposed Stipulations And Notice Of Contested Issues (Occupational Disease) Form. This is a Kentucky form and can be used in Workers Comp . |
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O.D. 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: ___________________________________________ 5. Employees was last exposed to the hazards of the disease while employed by this employer. 6. Employee had _______ years of exposure. 7. Employee had ______ single or ______ multiple exposure. 8. Employees date of birth: _____________________________________________________ 9. Employees educational level: ________________________________________________ 10. Employees specialized or vocational training: _____________________________________ 11. The following medical expenses are in dispute: Medical provider Service Date Amount Nature of Dispute 12. Other matters: ___________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ <<<<<<<<<********>>>>>>>>>>>>> 2 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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