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) 4. Address City 7. Employer 9. Address City State Zip Code Telephone State Zip Code Telephone 8. Insurer/Adjusting Company 10. Address City State Zip Code Telephone 2. Insurer Claim No. 3. Date of Injury 5. Social Security Number 6. Date of Birth I REQUEST THE OPPORTUNITY TO CROSS-EXAMINE THE FOLLOWING WITNESSES FOR THE REASONS STATED: 11. Date of Medical Summary Prepared By a. 12. Medical Report Date Report Author 13. Reason Cross-Examination is Requested (Be Specific) b. c. d. e. 14. Nonmedical Document Date Document Description a. 15. Document Author 16. Reason Cross-Examination is Requested (Be Specific) b. 17. Name of Person Submitting Request (Print or Type) 19. Address 18. Signature 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 NAME 21. Name of Person Serving Request 22. Signature ADDRESS ADDRESS 23. Date Served Form 07-6174 (1/94) American LegalNet, Inc. www.FormsWorkFlow.com 74