Request For Hearing - Final Award {WC-186} | Pdf Fpdf Doc Docx | Missouri

Request For Hearing - Final Award {WC-186}

Request For Hearing - Final Award {WC-186} | Pdf Fpdf Doc Docx | Missouri

Request For Hearing - Final Award Form

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This is a Missouri form that can be used for Workers Comp.

Last updated: 8/11/2012
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 1. INJURY NUMBER REQUEST FOR HEARING ­ FINAL AWARD + 2. Date of Injury 5. Case Venue 6. Party Requesting the Hearing Note: This form must be completed in its entirety and must be typed or hand printed in black ink. Please submit this form to the appropriate adjudication office. 3. Employee 4. Attorney for Employee 7. Employer(s)/Insurer(s) 8. Attorney for Employer/Insurer 9. Second Injury Fund Involved Yes No 10. Attorney for Second Injury Fund 11. Please state all issues to be resolved by hearing. 11a. The party requesting the hearing has conferred with all attorneys of record, whose names are listed here, regarding issues listed in No. 11. 12. Has all necessary discovery been completed? Yes No 12a. Are parties prepared to present their evidence at hearing? Yes No (The administrative law judge will consider a hearing request upon completion of discovery and parties' preparedness to present evidence at hearing.) 13. The party requesting the hearing has conferred with the other attorney of record and estimates the hearing will last approximately hour(s). 14. The party requesting a hearing must provide all exclusionary dates after conferring with all attorneys of record for all offices except Kansas City. The Exclusionary dates are 15. For cases venued in Jefferson City and Joplin, the party requesting the hearing has contacted the applicable office's docket clerk for available dates and has made a good faith effort to discuss these available dates with the other attorneys of record. Based on this information, the following dates, in order of preference, are requested for a hearing: Please Note Any party that objects to a hearing request must file a written objection within ten (10) days after the request for hearing is filed. If no objections are received and if no date has otherwise been determined, the docket clerk will schedule the hearing on the next available date. If objections are filed, the administrative law judge will review the objections and may schedule a conference call with parties prior to setting the case; may schedule a docket setting prior to setting the case; or determine the request for setting is premature and take such action as the administrative law judge deems necessary prior to setting the case. The administrative law judge's determination as to the request for setting shall be made within twenty (20) working days of the receipt of the request at the local adjudication office having venue over the case. CERTIFICATE OF SERVICE I, the undersigned, certify that, to the best of my knowledge, information and belief, the information set forth in this Request for Hearing ­ Final Award is true and accurate, and I further certify that a copy of this Request for Hearing ­ Final Award has been mailed or hand-delivered to all attorneys and/or parties of record this day of , 20 . Attorney's signature Bar Number Attorney's Name (Printed) Address Telephone Number COMPLETED BY DIVISION OF WORKERS' COMPENSATION Approved By Denied Date Please visit our website at www.labor.mo.gov/DWC if you have any questions about your rights or benefits under the Workers' Compensation Law. Keep a copy for your records. Date DIVISION USE ONLY + WC-186 WC-186 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com