DIVISION OF WORKERS' COMPENSATION ADJOURNMENT or READY HOLD FORM Fax/Mail/E-Mail to Court Vicinage and All Other Parties* AdjReq063016 Today's Date: Vicinage & Fax: E-Mail: If emailing, refer to instructions at bottom of form Hearing Date: ____________________ Check One: _ Judge ______________________________________ # on Hearing List: __________ ( Court Reporter Required Yes Adjournment Request for ________ cycles Ready Hold for _____________ (Time) No ) CP #: ____________________________ Case Title: ____________________________________________________________ ** Use additional pages if there are multiple cases to be adjourned for this Judge's hearing list Request by (Name of Attorney & Firm): __________________________________________________________________________ Counsel for (Check One): _____ _ _ Petitioner or Medical Provider __ Respondent Telephone Number: _______________________ Reason for Request (Required): FAX Number: _______________________ Petitioner to be examined by petitioner's expert Dr. __________________________________________ on __________________ Petitioner to be examined by respondent's expert Dr. _________________________________________ on __________________ Attorney conflict due to: ______________________________________________________________________________________ Petitioner continuing to receive ( Other (Be Specific): Authorized / Unauthorized) medical treatment. Other Case Parties Notified of this Request: *In requesting an Adjournment or Ready Hold you are certifying that all parties including co-respondents and, when applicable, the Deputy Attorney General and Special Counsel for the Uninsured Employers Fund have also received the request. Requests are to be made as soon as adjournment or ready hold basis is known. Requests are to be received (if mailed, ensure timely receipt) not less than 24 hours of the scheduled case listing date and time (for Monday lists or Tuesday lists after Monday holiday by 9 am of preceding Friday). Emergent requests (less than 24 hours) require telephone request to judge and parties. If request is denied, this form will be faxed to your office as indicated below. If denied, you are to notify all parties of the denial. If Checked, Request is Denied. Denial Reason: ___________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com E-Mail Instructions: Send completed document to the email address shown above, with Subject: "Adjournment Req mm/dd/yyyy - Office Name - Judge"