(Name, Address, Phone Number) ____________________________________ ____________________________________ ____________________________________ ____________________________________ IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA __________________________________, Petitioner ) ) ) ) ) WCC No. PETITION FOR HEARING (INJURY) __________________________________, Respondent/Insurer. As set forth in ARM 24.5.301 Petitioner alleges: 1. That on _______________, ____, Petitioner suffered an industrial injury arising out of and in the course of Petitioner's employment with _____________________________________________________________________ in __________________ County, Montana. Petitioner's _______________________ was injured when _______________________________________________________ _____________________________________________________________________ _____________________________________________________________________. 2. At the time of the injury, Petitioner's employer was enrolled under Compensation Plan No. ______ of the Workers' Compensation Act and its insurer is ____________________________________________________________________. 3. A dispute exists between the parties. Explain in detail the nature of the dispute. (Use additional pages if necessary.) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 4. Petitioner has exchanged all available pertinent medical records relating to the injury with Respondent and will continue to do so. 5. Check the appropriate paragraph below: ___ a. The parties have made an effort to resolve this dispute but have been unable to do so, and therefore a dispute exists which requires resolution by this Court. (For injuries occurring before July 1, 1987.) ___ b. The mediation procedure set forth in the Workers' Compensation Act has been complied with. (For injuries occurring on or after July 1, 1987.) American LegalNet, Inc. www.FormsWorkFlow.com *6. The following is a list of individuals who are potential witnesses for Petitioner in this matter: Name and Address General Subject Matter of Testimony * 7. The following is a list of written documents relating to this case which may be introduced as evidence by Petitioner: WHEREFORE, Petitioner respectfully prays that this petition be set for hearing and that the following relief be granted. (Explain what you want the Court to decide.) 1) ___________________________________________________________________ 2) ___________________________________________________________________ 3) ___________________________________________________________________ DATED this _____ day of _________________, 20__. _________________________________ Petitioner * If additional space is needed, please attach supplemental sheets to this PETITION FOR HEARING. Petition for Hearing (Injury) - Page 2 WCC (Mar-13) American LegalNet, Inc. www.FormsWorkFlow.com