ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 AFFIDAVIT OF READINESS FOR HEARING AWCB Case Number: Before you complete and submit this form, read carefully. Use only to request a hearing after an answer has been filed or at least 20 days after a Workers' Compensation Claim or petition was served, whichever comes first. Do not submit this form unless you are fully prepared for a hearing. Before your case will be set for a hearing, you must comply with the following instructions: I. Attach a completed "Medical Summary" (Form 07-6103) if you have new reports since your last Medical Summary, except as provided in 8 AAC 45.052. II. Attach a "Request for Cross-Examination" if you wish to cross-examine the authors of any medical reports listed on any party's "Medical Summary" to date. III. Mail this affidavit to the address of the city where you want the hearing held. 1. Employee's Name (Last, First, Middle Initial) 2. Date Received (Board Use Only) 3. Date of Injury 4. Address 5. Social Security Number 6. Date of Birth City State Zip Code Telephone 7. Insurer/Adjusting Company 8. Employer 9. Insurer Address 10. Employer Address City State Zip Code Telephone City State Zip Code Telephone 11. Is Employee now receiving compensation payments? Yes No Weekly Compensation Rate $ 12. Having first been duly sworn, I state that I have completed necessary discovery, obtained necessary evidence, and am fully prepared for a hearing on the issues set forth in the Workers' Compensation Claims(s) OR Petition(s) Dated Oral Hearing 13. Please Schedule (Choose one): Anchorage Location: 3301 Eagle Street, Suite 304 Anchorage AK 99503 Hearing on the Record Fairbanks 675 7th Avenue, Station K Fairbanks, AK 99701-4593 Hearing on the Record with Briefs Juneau P.O. Box 115512, Juneau AK 99811-5512 1111 W 8th St Rm 307, Juneau AK 99801 medical witnesses, and estimate 15. Telephone I requested an oral hearing and expect witnesses (not including witnesses who will testify by deposition), including the time required for my portion of the hearing will be hours. 14. Attorney Name and Firm Name (If represented) 16. Attorney Address City State Zip Code 17. Name of Affiant (Print or Type) 18. Signature (Sign in Front of Notary) City State Zip Code Telephone 19. Affiant Address NOTARY PUBLIC ______________________________________________________ Notary Public in and for the State of 20. PROOF OF SERVICE (Required): I certify that on the date in #23 below, I mailed a true and correct copy of the above affidavit to the following (affidavit will be returned with no action if all parties are not served): a. The employee in #1 above at the address in #4. b. The employer in #8 above at the address in #10. c. The insurer in #7 above at the address in #9 d. Other (name and address below): My Commission Expires: Subscribed and sworn to me this 21. Name of Person Serving Affidavit day of , 22. Signature 23. Date If a party receiving this affidavit is not ready for hearing, the party must serve on the other parties and file with the Division of Workers' Compensation, at the office checked in box #13, an Affidavit of Opposition within 10 days of the "Date Served" shown in box #23. If no Affidavit of Opposition is filed timely, a hearing will be set within 60 days. Form 07-6107 (Rev 04/2011) American LegalNet, Inc. www.FormsWorkFlow.com