Workers Compensation Appeals Docketing Statement

APPENDIX B ­ REVISED RULES OF APPELLATE PROCEDURE WORKERS' COMPENSATION APPEALS DOCKETING STATEMENT Complete Case Title: _______________________________________________________________ Petitioner: ________________________________Respondent: ______________________________ Counsel: _________________________________ Counsel: ________________________________ Claim No.: _______________________________ Board of Review No.: ______________________ Date of Injury/Last Exposure: ________________ Date Claim Filed: _________________________ Date and Ruling of the Office of Judges: ________________________________________________ Date and Ruling of the Board of Review: _______________________________________________ Issue and Relief requested on Appeal: __________________________________________________ CLAIMANT INFORMATION Claimant's Name: __________________________________________________________________ Nature of Injury: ___________________________________________________________________ Age: _________ Is the Claimant still working? Yes No. If yes, where: _______________ Occupation: ___________________________________________ No. of Years: ________________ Was the claim found to be compensable? Yes No If yes, order date: ____________________ ADDITIONAL INFORMATION FOR PTD REQUESTS Education (highest): _______________________ Old Fund or New Fund (please circle one) Date of Last Employment: ___________________________________________________________ Total amount of prior PPD awards: _____________________ (add dates of orders on separate page) Finding of the PTD Review Board: ____________________________________________________ List all compensable conditions under this claim number: ___________________________________ (Attach a separate sheet if necessary) Are there any related petitions currently pending or previously considered by the Supreme Court? Yes No (If yes, cite the case name, docket number and the manner in which it is related on a separate sheet.) Are there any related petitions currently pending below? Yes No (If yes, cite the case name, tribunal and the manner in which it is related on a separate sheet.) If an appealing party is a corporation an extra sheet must list the names of parent corporations and the name of any public company that owns ten percent or more of the corporation's stock. If this section is not applicable, please so indicate below. The corporation who is a party to this appeal does not have a parent corporation and no publicly held company owns ten percent or more of the corporation's stock. Do you know of any reason why one or more of the Supreme Court Justices should be disqualified from this case? Yes No If so, set forth the basis on an extra sheet. Providing the information required in this section does not relieve a party from the obligation to file a motion for disqualification in accordance with Rule 33. 106 American LegalNet, Inc. www.FormsWorkFlow.com