PETITION TO DETERMINE COMPENSATION DUE TO INJURED EMPLOYEE To the Industrial Accident Board of the State of Delaware Sitting in and for County Claimant SS# Claimant Date of Birth vs. Insurance Carrier Case File No. Employer The undersigned petitioner respectfully represents: That the above named claimant and the above named employer have failed to reach an agreement in regard to compensation due said claimant as an employee of said employer. The undersigned therefore prays that your Honorable Board shall, after due notice of the time and place of hearing served on all parties in interest, hear and determine the matter in accordance with the facts and the law and state its conclusions of fact and rulings of law. My signature on this petition is authorization for any doctor, hospital, other health care provider, or State of Delaware Division of Vocational Rehabilitation to supply any and all medical records and reports to the bearer of the original or a copy of this petition regarding any medical condition provided all requests for this information are in writing. Dated this day of A.D. 20 Claimant222s Signature Name of Attorney, if applicable Document Control # A60-07-05-08-12 } American LegalNet, Inc. www.FormsWorkFlow.com INDUSTRIAL ACCIDENT BOARD STATE OF DELAWARE Statement of Facts Upon Failure to Reach an Agreement 1.Name of Employee Address City State Zip Telephone Number E-mail (optional) 2.Date of Accident 3. Place of Accident4.Name of EmployerEmployer Contact Name E-mail (optional) Address City State Zip Telephone Number Fax # 5.Name of Insurance Carrier / 3rd Party Administrator6.Occupation of employee at the time of accident7.Describe accident/illness and how it happened8.List the body part(s)/illness9.Did employee receive medical, surgical or hospital service? Yes No 10.When was notice of injury given to or received by employer?11.Give names and addresses of all employers for the last 5 years. If more space is needed, attacha separate sheet.NAME:ADDRESS: 12.State weekly wage when injured American LegalNet, Inc. www.FormsWorkFlow.com 13.State names and addresses of all treating doctors for this claim. If more space is needed, attacha separate sheet. NAME:ADDRESS: 14.State names and address of all other treating doctors for the last 10 years. If more space isneeded, attach a separate sheet.NAME:ADDRESS: 15.Give names and addresses and dates of treatment of all hospitals and institutes treating youfor this injury. If more space is needed, attach a separate sheet.NAME:ADDRESS: 16.To what extent did injury prevent employee from working and for how long17.State whether or not employee has fully recovered and if only partially to what extent18.If employee has resumed work, statea)when and give name of present employerb)what trade or occupation and weekly wages19.Identify, give description and dates of all previous and subsequent injuries. 20.State any other important facts bearing on the case above presented American LegalNet, Inc. www.FormsWorkFlow.com