Free H - Kentucky

H.L. COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS CLAIMS CLAIM NO(S). _____________________ BEFORE ALJ __________________________ _____________________________________________ VS. _____________________________________________ _____________________________________________ STATEMENT OF PROPOSED STIPULATIONS AND NOTICE OF CONTESTED ISSUES ************************************************* I. STIPULATIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Coverage under the Act. The employer had due and timely notice of the employee's claim. Employee's average weekly wage. Employee's last date of exposure to industrial noise: ________________________________ Employee's was last exposed while employed by this employer. Employee was exposed to industrial noise for _______ years while employed by this employer. Employee's date of birth: _____________________________________________________ ________________________________________________ Employee's educational level: DEFENDANT(S) PLAINTIFF

Employee's specialized or vocational training: _____________________________________ The following medical expenses are in dispute: Service Date Amount Nature of Dispute

Medical provider

11.

Other matters:

___________________________________________________________

________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

II. The following issues are contested: 1. 2. 3. 4. 5.

CONTESTED ISSUES

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ III. DESIGNATION OF EVIDENCE IN BENEFIT REVIEW RECORD

The following evidence in the benefit review record is designated for consideration by the Administrative Law Judge: 1. 2. 3. 4. 5. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ************************************************* PLEASE NOTE: 1. 2. All matters not in controversy should be stipulated. The issues listed above will be considered by the Administrative Law Judge. This the _______ day of ______________________________, 200___. __________________________________________ Attorney

Revised: 12/12/01