Uniform Statewide Pretrial Stipulation | Pdf Fpdf Doc Docx | Florida

Uniform Statewide Pretrial Stipulation

Florida/Workers Comp/
Uniform Statewide Pretrial Stipulation | Pdf Fpdf Doc Docx | Florida

Uniform Statewide Pretrial Stipulation Form

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

Last updated: 3/24/2008
STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS DISTRICT _____________ JUDGE _______________ OJCC Case No.: _____________________ EMPLOYEE/CLAIMANT: Name: ______________________________ Address: ____________________________ Telephone number: ____________________ E-mail ______________________________ EMPLOYER: Name: ______________________________ Address: ____________________________ Telephone number: ____________________ E-mail ______________________________ CARRIER/SERVICING AGENT: Date of Accident(s)______________________ ATTORNEY FOR EMPLOYEE: Name: _________________________________ Address: _______________________________ Telephone number: _______________________ E-mail _________________________________ ATTORNEY FOR EMPLOYER: Name: _________________________________ Address: _______________________________ Telephone number: _______________________ E-mail _________________________________ ATTORNEY FOR CARRIER/SERVICING AGENT: Name: ______________________________ Name: _________________________________ Address: ____________________________ Address: _______________________________ Telephone number: ____________________ Telephone number: _______________________ E-mail ______________________________ E-mail _________________________________ _____________________________________________________________________________ UNIFORM STATEWIDE PRETRIAL STIPULATION (Revised 6/07) ______________________________________________________________________________ Important: The Joint Pretrial Stipulation is to be filed in the Judge's office, completed by all parties, within five (5) days of the mediation conference. See 60Q-6.110(7). As authorized under Rule 60Q-6.113, and as ordered by the Office of Judges of Compensation Claims, the parties hereby provide the following information and make the following stipulations: I. STIPULATIONS 1. Date of Accident(s): Employee: ____________________ E/C/SA: ______________________ 3. Mediation held: Employee: ____________________ E/C/SA: ______________________ 2. Place of Accident(s) or agreed county/venue: Employee: ____________________________________ E/C/SA: ______________________________________ 4. Final Hearing set: Employee: ____________________________________ E/C/SA: ______________________________________ OJCC Case No.: Page 1 of 6 American LegalNet, Inc. www.FormsWorkflow.com Questions 5 through 7 to be completed by the Employer/Carrier/Servicing Agent. 5. Employer/Employee relationship on date of accident: 6. Workers' Compensation insurance coverage on date of accident: 7. Accident or occupational disease accepted as compensable: ____YES ___NO ____YES ___NO ____YES ___NO 8. The Employee asserts the following specific body parts/psychiatric conditions are related to the accident: Employee: ________________________________________________________________ 9. The E/C/SA agree that the following specific body parts/psychiatric conditions are accepted as related to the accident: E/C/SA: __________________________________________________________________ 10. Timely notice of accident, injury or occupational disease: Employee: ___________________________; to whom: ____________________________ (Date notice given) E/C/S/A: ____________________________; to whom: ____________________________ (Date notice given) 11. Timely notice of final hearing? Employee: ____YES ___NO 12. Is case governed by a managed care arrangement? Employee: ____YES ___NO E/C/SA: ____YES ___NO E/C/SA: ____YES ___NO 13. Jurisdiction of Judge of Compensation Claims over the subject matter and parties: Employee: ____YES ___NO E/C/SA: ____YES ___NO 14. Average Weekly Wage. Note: If there is a dispute as to the AWW, each party shall attach copies of all relevant records and weekly wage statements. Employee E/C/SA Base Wage: ___________________ Fringe Benefit: ________________ Total: ________________________ Base Wage: ___________________ Fringe Benefit: _________________ Total: ________________________ 15. Maximum medical improvement, if reached list date, name of physician, and impairment rating. Employee E/C/SA Date: ______________________________ Dr: _______________________________ Rating: _____________________________ Statutory MMI date: ___________________ OJCC Case No.: Page 2 of 6 ______________________________ ______________________________ ______________________________ ______________________________ American LegalNet, Inc. www.FormsWorkflow.com 16. If benefits under F.S.440.13 (medicals) are determined to be due or stipulated due herein, the parties agree that the exact amounts payable to health providers will be handled administratively and medical bills need not be placed into evidence at trial: Employee: ____YES ___NO 17. Medical treatment authorized: Employee: ______________________________________________________________ E/C/SA: ________________________________________________________________ 18. IME Physicians: Employee: ______________________________________________________________ E/C/SA: ________________________________________________________________ 19. EMA Physicians: Employee: ______________________________________________________________ E/C/SA: ________________________________________________________________ 20. Classification and periods of time for which benefits were paid: Employee: ______________________________________________________________ E/C/SA: ________________________________________________________________ 21. Payout ledger stipulated into evidence? If so, attach a copy. Employee: ____YES ___NO 22. Date petition for benefit(s) filed with Division: Employee: ______________________________________________________________ E/C/SA: ________________________________________________________________ 23. Dates Notices of Controvert/Denial/Responses to Petition for Benefit filed: Employee: ______________________________________________________________ E/C/SA: ________________________________________________________________ 24. Other Stipulations: ___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Employee Agrees: _______