Montana > Workers Compensation
Petition For Hearing (Occupational Disease) - Montana
| Petition For Hearing (Occupational Disease) Form. This is a Montana form and can be used in Workers Compensation . |
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(Name, Address, Phone Number) ____________________ _______________ _ ____________________ _______________ _ ____________________ _______________ _ ____________________ _______________ _ IN THE WORKERS COMPENSATION COURT OF THE STATE OF MONTANA WCC NO. ___________________ (leave blank) ____________________ _________________ Petitioner vs. ________________________ ______________ Respondent/Insurer. PETITION FOR HEARING (Occupational Disease) As set forth in ARM 24.5.301 petitioner alleges: 1. That on _______________, ____, petitioner became aware of an occupational disease arising out of or contracted in the course and scope of her/his employment with ____________________ _____________ _ in _______________________ _ County, Montana. Petitioner suffers from the following disease: _________________ ____________________ ____________________ _____________________ which originated through employment as follows: ________________________ ________________________ ________________ __________________ _ ________________________ ____________________ _______________________________ _________________________ ____________________ _______________________________ _ 2. At the time of the injury, petitioners employer was enrolled under Compensation Plan <<<<<<<<<********>>>>>>>>>>>>> 2______of the Workers Compensation Act and its insurer is__________________ ____________________ __________________. 3. A dispute exists between the parties. Explain in detail the nature of the dispute. (Use additional pages if necessary.) ________________________ ____________________ _______________________________ _________________________ ____________________ _______________________________ _________________________ ____________________ _______________________________ _ 4. Petitioner has exchanged all available pertinent medical records relating to the injury with the defendant and will continue to do so. 5. Check the appropriate paragraph below: ___ a. The parties have made an effort to resolve this dispute but have been unable to do so, and therefore a dispute exists which requires resolution by this Court. (For injuries occurring before July 1, 1987.) ___ b. The mediation procedure set forth in the Workers Compensation Act has been complied with. (For injuries occurring after July 1, 1987.) *6. The following is a list of individuals who are potential witnesses for petitioner in this matter: Name and Address General Subject Matter of Testimony ________________________ ____________________ _______________________________ _________________________ ____________________ _______________________________ _________________________ ____________________ _______________________________ _* 7. The following is a list of written documents relating to this case which may be introduced as evidence by petitioner: ________________________ ____________________ _______________________________ _ ________________________ ____________________ _______________________________ _ ________________________ ____________________ _______________________________ _WHEREFORE , petitioner respectfully prays that this petition be se t for hearing and that the following relief be granted. (Explain what you want the Court to decide.) <<<<<<<<<********>>>>>>>>>>>>> 31) ________________________ ____________________ _______________________________ _ 2) ________________________ ____________________ _______________________________ _ 3) ________________________ ____________________ _______________________________ _ DATED this _____ day of ________________ _, 20____. ________________ ______________ _ Pe titi one r * If additional space is needed, please attach sheet to this petition for hearing.
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