(Name, Address, Phone Number) ____________________________________ ____________________________________ ____________________________________ ____________________________________ IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA _____________________________________) Petitioner ) ) vs. ) _____________________________________) DISEASE) Respondent/Insurer. As set forth in ARM 24.5.301 Petitioner alleges: 1. That on _______________, ____, Petitioner became aware of an occupational disease arising out of or contracted in the course and scope of Petitioner's employment with _______________________________________ in ________________________ County, Montana. Petitioner suffers from the following disease:_________________ __________________________________________ which originated through employment as follows:___________________________________________________ . 2. At the time of the occupational disease 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.) WCC No. PETITION FOR HEARING (OCCUPATIONAL 4. Petitioner has exchanged all available pertinent medical records relating to the occupational disease with Respondent and will continue to do so. American LegalNet, Inc. www.FormsWorkFlow.com 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.) *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 sheet to this PETITION FOR HEARING. Petition for Hearing (Occupational Disease) - Page 2 WCC (Mar-13) American LegalNet, Inc. www.FormsWorkFlow.com