Oregon > Workers Comp > Hearings
Request For Hearing And Specification Of Issues 438-342 - Oregon
| Request For Hearing And Specification Of Issues Form. This is a Oregon form and can be used in Hearings Workers Comp . |
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Before the WORKERS' COMPENSATION BOARD State of Oregon In the Matter of the Compensation of Name Address Phone # Claimant's Attorney Oregon State Bar Number Attorney Firm Address Request for Hearing and Specification of Issues Date of Injury Claim # (only one claim number per form) SS # WCD File # Employer Address Insurer Address (optional) Phone # A hearing is requested for the reason(s) checked below: A DENIAL (date) B X Z V Compensability - complete claim denial Partial denial after a claim acceptance Challenge to notice of acceptance Worker noncooperation N ORDER ON RECONSIDERATION attach copy Y Classification (disabling/nondisabling) I Premature closure D Substantive TTD/TPD Period sought K Aggravation L Responsibility O Own Motion C Medical Services Compensability/Causation M NONCOMPLYING EMPLOYER ORDER TTD/TPD R Rate D Procedural entitlement Period sought E Scheduled disability F Unscheduled disability G Permanent total disability Q OTHER (Explain and cite ORS) P DIRECTOR'S ORDER attach copy S PENALTY (Cite ORS) T ATTORNEY FEE (Cite ORS) U TEMPORARY DISABILITY OFFSET · INTERPRETER WILL BE NEEDED Yes No LANGUAGE __________________ · The amount in controversy is LESS than $1000. Yes No · All day is required for hearing. Yes No · Stress claim (such claims will be set for all day unless otherwise requested) Yes No · Compensation Stayed (Employer/insurer appeal of WCD Reconsideration Order) Yes No · Please give this request for hearing a different WCB case number Yes No and hearing date from any pending case(s) regarding this claim or claimant · Please consolidate this request for hearing with the following pending case(s) regarding this claim or claimant: WCB Case No(s) _______________________________________________________ Signature of Requester Request by Attorney/Claimant Claimant Insurer/Processing Agent Employer DCBS ______ Yes No ___________________ Date NOTICE TO OPPOSING PARTY: The requester demands copies of all medical reports and all other documents pertaining to this claim, whether or not the requesting party intends to rely on them at hearing. American LegalNet, Inc. www.USCourtForms.com 438-342(8/03WCB) Date Received
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