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Statement Of Proposed Stipulations And Notice Of Contested Issues (Hearing Loss) Form. This is a Kentucky form and can be use in Workers Comp.
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Tags: Statement Of Proposed Stipulations And Notice Of Contested Issues (Hearing Loss), Kentucky Workers Comp,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
H.L.
COMMONWEALTH OF KENTUCKY
:
JUDICIAL SUBPOENA
Plaintiff(s)
DEPARTMENT OF WORKERS CLAIMS
-against- NO(S). _____________________
:
CLAIM
BEFORE ALJ __________________________
:
_____________________________________________
VS.
PLAINTIFF
:
Defendant(s)
:
......................................................
_____________________________________________
_____________________________________________
DEFENDANT(S)
THE PEOPLE OF THE STATE OF NEW YORK
STATEMENT OF PROPOSED STIPULATIONS
AND
NOTICE OF CONTESTED ISSUES
TO
*************************************************
I.
STIPULATIONS
GREETINGS:
1.
2.
3.
WE under the Act.
Coverage COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
The employer had due andlocated at
timely notice of the employee's claim.
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Employee's average weekly wage.
or adjourned date, to testify and give evidence as a witness in this action on the part of the
4.
Employee's last date of exposure to industrial noise: ________________________________
5.
Employee's was last exposed while employed by this employer.
6.
7.
8.
9.
10.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
Employee was exposed subpoena was issued for _______ years while employed by this employer.
the party on whose behalf this to industrial noise for a maximum penalty of $50 and all damages sustained as a
result of your failure toof birth: _____________________________________________________
Employee's date comply.
Employee's educational level:
Witness, Honorable
________________________________________________
, one of the Justices of the
Court in
County,
day of
, _____________________________________
Employee's specialized or vocational training: 20
The following medical expenses are in dispute:
Medical provider
Service
Date
(Attorney must sign above and type name below)
Amount
Nature of Dispute
Attorney(s) for
Office and P.O. Address
11.
Other matters:
___________________________________________________________
Telephone No.:
________________________________________________________________________________
Facsimile No.:
E-Mail Address:
________________________________________________________________________________
Mobile Tel. No.:
________________________________________________________________________________
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
II.
Index No.
Calendar No.
CONTESTED ISSUES
The following issues are contested: Plaintiff(s)
-against-
:
JUDICIAL SUBPOENA
:
1.
___________________________________________________________________________
2.
:
___________________________________________________________________________
3.
___________________________________________________________________________
:
4.
___________________________________________________________________________
Defendant(s)
:
......................................................
5.
___________________________________________________________________________
THE PEOPLE OF THE STATE OF NEW YORK
III.
DESIGNATION OF EVIDENCE IN BENEFIT REVIEW RECORD
The following evidence in the benefit review record is designated for consideration by the
TO
Administrative Law Judge:
1.
______________________________________________________________________
2.
GREETINGS:
3.
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend
______________________________________________________________________ before
,
the Honorable
at the
Court
______________________________________________________________________
located at
County of
in______________________________________________________________________recessed
room
, on the
day of
, 20
, at
o'clock in the
noon, and at any
or adjourned date, to testify and give evidence as a witness in this action on the part of the
4.
5.
______________________________________________________________________
*************************************************
1.
2.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
PLEASE NOTE:
result of your failure to comply.
All matters not in controversy should be stipulated.
Witness, Honorable
, Law the Justices of the
The issues listed above will be considered by the Administrativeone of Judge.
Court in
County,
day of
, 20
This the _______ day of ______________________________, 200___.
(Attorney must sign above and type name below)
__________________________________________
Attorney Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Revised: 12/12/01
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