KANSASDEPARTMENTOFLABOR www.dol.ks.gov Page1of2 PRETRIAL STIPULATIONS (Kansas Adm. Reg. 51-3-8) K-WC139(Rev.12-12) Re: ___________________________________________ClmtAtty: _________________________________________ vs:____________________________________________RespAtty:_________________________________________ and:___________________________________________FundAtty:_________________________________________ DocketNo.:_____________________________________DateofHearing:____________________________________ Notice of Hearing Objections? Questions to Claimant: Form?________________________Service?_________________________ 1. Inwhatcountyisitclaimedthatclaimantmetwithpersonalinjurybyaccidentorrepetitivetrauma? _______________ Dothepartiesstipulatethattheregularhearingmaybeconductedinthecountyinwhichitisscheduledtobeheld? YES NO(OR:Thepartiesstipulatethatthehearingmaybeheldin________________________county.) 2. Uponwhatdate(s)isitclaimedthatclaimantmetwithpersonalinjury: a)Byaccident?________________________________________________________________________________ b)Byrepetitivetrauma?__________________________________________________________________________ Questions to Respondent: 1. 2. Doesrespondentadmitthatclaimantmetwithpersonalinjury byaccidentonthedatealleged? Doesrespondentadmitthatclaimantmetwithpersonalinjury byrepetitivetraumaonthedatealleged? Admitted Denied Denied Denied Denied Denied Denied Admitted Admitted Admitted Admitted Admitted 3. Doesrespondentadmitthatclaimant'sallegedpersonalinjury "aroseoutofandinthecourseof "claimant'semployment? 4. Doesrespondentadmitpropernotice? 5. Doesrespondentadmitthattherelationshipofemployerandemployee existedonthedate(s)oftheallegedaccidentorrepetitivetrauma? 6. Doesrespondentadmitthatthepartiesarecoveredbythe KansasWorkersCompensationAct? 7. Didrespondenthaveaninsurancecarrieronthedate(s)oftheallegedaccidentorrepetitivetrauma? YES NO IfYES,nameofcompany: ________________________________________________________________________ Wastherespondentself-insured? YES NOAmemberofagroup-fundedpool? YES NO 8. Doesrespondentadmitthattheaccidentorrepetitivetraumawastheprevailingfactorcausingtheinjury,themedical condition,needfortreatmentandtheresultingdisabilityorimpairment? Admitted Denied DIVISIONOFWORKERSCOMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone:(785)296-4000·Tollfree:(800)332-0353·Email:wc@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com KansasDepartmentofLabor Pretrial Stipulations K-WC139(Rev.12-12) Page2of2 Questions to Both Parties: 1. Isthereanagreementontheaverageweeklywage? YES NOIfYES,amount:$______________________ Ifnoagreement,thenpartiesareexpectedtoprovidemewiththisinformationwithin30daysofthisdate.Ifnotreceived withinthattime,therespondentwillbeboundbyclaimant'stestimony. YES NO TemporaryPartial Totalamount:$_____________________________ Numberofweeks: ___________________________ Dates:____________________________________ Rate:_____________________________________ IfYES: TemporaryTotal Totalamount:$____________________________ Numberofweeks: _________________________ Dates:___________________________________ Rate:____________________________________ Agreed: YES NO 2. Hasanycompensationbeenpaid? 3. Whataretheadditionaldatesoftemporarytotaldisability,ifanyareclaimed?___________________________________ 4. a)Hasanymedicalorhospitaltreatmentbeenfurnished? b)Whatmedicalandhospitalexpenseshavebeenpaid? (Readintorecordamountpaidandtowhompaid) YES NO Totalamount:$______________ YES NO c)Isclaimantmakingclaimforanyfuturemedicaltreatment? 5. Hasclaimantincurredanymedicalorhospitalexpenseforwhichreimbursementisclaimed? Bills: YES NO (Readintorecordorsubmitbyletterwithin30days) Mileage: YES NO (Readintorecordorsubmitbyletterwithin30days) UnauthorizedMedical: YES NO YES Amount: $_________________ Amount: $_________________ Amount: $_________________ NO 6. Areeithernatureorextentofdisabilityanissue? IfNO,whatarethenatureandextentofthedisability? _____________________________________________________ _________________________________________________________________________________________________ YES NO 7. IstheWorkers'CompensationFundtobeimpleadedasanadditionalparty? Fund'sliability? ____________________________________________________________________________________ _________________________________________________________________________________________________ YES NOIfYES,rating:____________________ 8. Isthereanagreementuponafunctionalimpairmentrating? IfNO,whatratingsareavailable? 9. Whatevidenceisscheduledbytheclaimant? ____________________________________________________________ 10. Bytherespondent? ________________________________________________________________________________ Terminal Dates Claimant:____________________Respondent:____________________Fund:________________________________ DIVISIONOFWORKERSCOMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone:(785)296-4000·Tollfree:(800)332-0353·Email:wc@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com