Request For Cross Examination
Request For Cross Examination Form. This is a Alaska form and can be use in Workers Comp.
Tags: Request For Cross Examination, 07-6174, Alaska Workers Comp,
ALASKA DEPARTMENT OF LABOR Alaska Workers Compensation Board P.O. Box 25512 Juneau, Alaska 99802-5512 AWCB Case Number Request for Cross-Examination Instructions: This form is to be filed to request cross-examination of the author of any report listed on a Medical Summary or any nonmedical document. To be used when you file an Affidavit of Readiness for Hearing, an Affidavit of Opposition, or a Medical Summary or within 10 days after another party files a Medical Summary. 1. Employees Name (Last, First, Middle Initial) 2. Insurer Claim No. 3. Date of Injury 4. Address City 5. Social Security Number State Zip Code Telephone 7. Employer 8. Insurer/Adjusting Company 9. Address City 6. Date of Birth 10. Address State Zip Code Telephone City State Zip Code Telephone I REQUEST THE OPPORTUNITY TO CROSS-EXAMINE THE FOLLOWING WITNESSES FOR THE REASONS STATED: 11. Date of Medical Summary Prepared By 12. Medical Report Date 13. Reason Cross-Examination is Requested (Be Specific) Report Author a. b. c. d. e. 14. Nonmedical Document Date 15. Document Author 16. Reason Cross-Examination is Requested (Be Specific) Document Description a. b. 17. Name of Person Submitting Request (Print or Type) 18. Signature 19. Address City State Zip Code Telephone 20. PROOF OF SERVICE: I certify that on the date in #23 below I mailed/delivered a true and correct copy of this request to the following (request will be returned with no action if all parties are not served): a. o The employee in #1 above at the address in #4 b. o The employer in #7 above at the address in #9. c. o The insurer in #8 above at the address in #10. d. o Other (state name and address): NAME ADDRESS NAME ADDRESS 21. Name of Person Serving Request Form 07-6174 (1/94) 22. Signature 23. Date Served 74 2001 © American LegalNet, Inc.