October 2016 Edition OCCUPATIONAL DISEASE 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 Plaintiff/Employee's claim: Yes At issue . At issue , 20 . At issue . 3. Plaintiff/Employee's average weekly wage: 4. Plaintiff/Employee's date of last exposure: 5. Plaintiff has developed the occupational disease of: 6. Plaintiff/Employee was last exposed to the hazards of the disease while employed by this Defendant/Employer. 7. Plaintiff/Employee had 8. Plaintiff/Employee 9. Plaintiff/Employee When? 10. is has , 20 . Yes At issue years of exposure. At issue is not continuing to be exposed to the hazards of this disease. has not returned to work. If Plaintiff/Employee returned to work, Where? _, . American LegalNet, Inc. www.FormsWorkFlow.com . Plaintiff/Employee's date of birth: 11. Plaintiff/Employee's education level: 12. The following medical expenses are in dispute: Medical Provider Service Date Amount Nature of Dispute . 13. 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