Delaware > Workers Compensation
Petition To Determine Compensation Due To Injured Employee - Delaware
| Petition To Determine Compensation Due To Injured Employee Form. This is a Delaware form and can be used in Workers Compensation . |
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Form 13 PETITION TO DETERMINE COMPENSA TION DUE TO INJURED EMPLOYEE _________________________ To the Industrial Accident Board of the State of Delaware Sitting in and for County ___________________________Claimant Claimant SS# _____________________ vs. DOB _____________________ ________________________________ } ___________________________Employer Ins. Carrier _______________________ The undersigned petitioner respectfully represents: That the above named claimant and the above named employer have failed to reach an agreement in regard to compensation due said claimant as an employee of said employer. The undersigned therefore prays that your Honorable Board shall, after due notice of the time and place of hearing served on all parties in interest, hear and determine the matter in accordance with the facts and the law and state its conclusions of fact and rulings of law. My signature on this petition is authorizaon for any doctor or hospital or other health ti care provider to supply any and all medical records and reports to the bearer of the original or a copy of this petition regarding any medical condition provided all requests for this information are in writing. Dated this ________________________________day of ____________________A. D. 20____ ______________________________________ N ame ______________________________________ DOCUMENT NO. 60-07/89/01/05-L 57 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 A ddress INDUSTRIAL ACCIDENT BOARD STATE OF DELAWARE _______________ Statement of Facts Upon Failure to Reach an Agreement 1. Name of Employee _________________________________________________________ 2. Residence of employee ______________________________________________________ 3. Employees Telephone Number _______________________________________________ 4. Date of Accident __________________________________________________ _________ 5. Place of Accident ___________________________________________________________ 6. By whom employed at the time of accident _______________________________________ 7. Occupation of employee at the time of accident ____________________________________ 8. Nature of accident and how it happened __________________________________________ ________________________________________________________________________ _____ ________________________________________________________________________ _____ 9. Describe the nature of injury _____________________________________ ______________ ________________________________________________________________________ _____ ________________________________________________________________________ _____ ________________________________________________________________________ _____ 10. Did employee receive medical, surgical or hospital service ___________________________ ________________________________________________________________________ ______ 11. When was notice of injury given to or received by employer _________________________ ________________________________________________________________________ ______ 12. Give names and addresses of all employers for the last 5 years ________________________ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ 13. State weekly wage when injured ________________________________________________ 14. State names and addresses of all treating doctors for this claim ________________________ ________________________________________________________________________ ______ DOCUMENT NO. 60-07/89/01/05-L 57 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 ________________________________________________________________________ ______ 15. State names and address of all other treating doctors for the last 10 years _____________ ________________________________________________________________________ ___ ________________________________________________________________________ ___ ________________________________________________________________________ ___ 16. Give names and addresses and dates of treatmnt of all hospitals and institutes treating you e for this injury ________________________________________________________ ________ ________________________________________________________________________ ____ ________________________________________________________________________ ____ 17. To what extent did injury prevent employee from working and for how long ___________ ________________________________________________________________________ ____ ________________________________________________________________________ ____ 18. State whether or not employee has fully recovered and if only partially to what extent ____ ________________________________________________________________________ _____ 19. If employee has resumed work state when and give name of present employer ___________ ________________________________________________________________________ _____ 20. State what trade or occupation and weekly wages __________________________________ ________________________________________________________________________ ______ 21. If employee has not resumed work state how long likely to be incapacitated from doing so ________________________________________________________________________ ______ 22. Give description and dates of all previous and subsequent injuries and identify all ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ 23. State any other important facts bearing on the case above presented ____________________ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ Dated this _______________________ day of ___________________________A.D . 20 ______ _________________________________________ DOCUMENT NO. 60-07/89/01/05-L 57 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4 Name DOCUMENT NO. 60-07/89/01/05-L 57 American LegalNet, Inc. www.USCourtForms.com
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