Free H - Kentucky

O.D. 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. 11. 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: ___________________________________________ Employee's was last exposed to the hazards of the disease while employed by this employer. Employee had _______ years of exposure. Employee had ______ single or ______ multiple exposure. 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

12.

Other matters:

___________________________________________________________

___________________________________________________________________________ ___________________________________________________________________________

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

CONTESTED ISSUES

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ************************************************* 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