October 2016 Edition INJURY 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. An employment relationship existed between the plaintiff/employee and defendant/employer at all relevant times: Yes At issue , 20 . 3. Plaintiff/Employee sustained a work-related accident/injury(ies) on: Yes At issue 4. The Defendant/Employer received due and timely notice of Plaintiff/Employee's accident and injury(ies): Yes At issue , 20 . At issue per week from . . If at issue, when did the Defendant/Employer receive notice? 5. Plaintiff/Employee's average weekly wage: 6. Temporary total disability benefits were paid at the rate of $ through Start date End date , for a total of $ 7. The Defendant/Employer has paid a total of $ injury. for medical expenses as a result of this American LegalNet, Inc. www.FormsWorkFlow.com 8. The following medical expenses are in dispute: Medical Provider Service Date Amount Nature of Dispute 9. Plaintiff/Employee returned to work: 10. Plaintiff/Employee is working currently Yes Yes No No At issue At issue . At issue 11. Plaintiff/Employee's weekly wage upon return to work: $ 12. Plaintiff/Employee retains the physical capacity to perform the type of work he/she did at date of injury: Yes At issue , . . 13. Plaintiff/Employee's date of birth: 14. Plaintiff/Employee's education level: 15. Plaintiff/Employee's specialized or vocational training: . 16. 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