October 2016 Edition HEARING LOSS STIPULATION AND CONTESTED ISSUES KENTUCKY DEPARTMENT OF WORKERS' CLAIMS CLAIM NO(S). BEFORE ALJ PLAINTIFF/EMPLOYEE VS. DEFENDANT/EMPLOYER(S) STATEMENT OF PROPOSED STIPULATIONS AND NOTICE OF CONTESTED ISSUES I. STIPULATIONS 1. Coverage under the Act: Yes At issue 2. The defendant/employer had due and timely notice of the employee's claim: Yes At issue At issue 3. Plaintiff/Employee's average weekly wage: 4. Plaintiff/Employee's last date of exposure to industrial noise or date of accident leading to hearing loss: , 20 . At issue If long term noise exposure is basis of claim, complete items 5 and 6. 5. Plaintiff/Employee was last exposed while employed by this defendant/employer. Yes At issue years while employed by this 6. Plaintiff/Employee was exposed to industrial noise for Defendant/Employer. At issue , 7. Plaintiff/Employee's date of birth: 8. Plaintiff/Employee's educational level: 9. Plaintiff/Employee's specialized or vocational training: . . . American LegalNet, Inc. www.FormsWorkFlow.com 10. The following medical expenses are in dispute: Medical Provider Service Date Amount Nature of Dispute 11. Other matters: II. CONTESTED ISSUES The following issues are contested: 1. 2. 3. 4. 5. PLEASE NOTE: 1. All matters not in controversy should be stipulated. 2. The issues listed above will be considered by the Administrative Law Judge. This the day of , 20_ . Attorney American LegalNet, Inc. www.FormsWorkFlow.com