Free H - Kentucky

INJURY 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. Coverage under the Act. An employment relationship existed between the employee and employer at all relevant times. Employee sustained a work-related injury(ies) on ____________________________________ The employer received due and timely notice of employee's injury(ies). Employee's average weekly wage. Temporary total disability benefits were paid at the rate of $___________ per week from _____________________ through _______________________, for a total of $___________. The employer has paid a total of $___________ for medical expenses as a result of this injury. The following medical expenses are in dispute: Service Date Amount Nature of Dispute DEFENDANT(S) PLAINTIFF

Medical provider

9. 10. 11. 12.

Employee _______ has _______ has not returned to work. Employee's current weekly wage is $_____________________________________________ Employee _______ does _______ does not retain physical capacity to perform the type of work he did at date of injury. Employee's date of birth: _____________________________________________________

13. 14. 15.

Employee's educational level: Other matters:

________________________________________________

Employee's specialized or vocational training: _____________________________________ ___________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ II. The following issues are contested: CONTESTED ISSUES

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