U.S. Department of Labor Office of Administrative Law Judges 90 Seventh Street, Suite 4-800 San Francisco, CA 94103-1516 Case Caption and No. _________________________________________________________________ PRETRIAL STATEMENT of: Director, OWCP Claimant __________________________________________ Respondent __________________________________________ 1. Briefly summarize, below or on attached sheet, the facts or circumstances you contend gave rise to this claim, and describe the nature of the claimed injury or disease. 2. State your contentions as to the place of injury ___________________________________________; its date ___________ ; the date disability commenced ____________; the date claimant became aware disability was work related ___________ ; and the date employer had notice of injury ____________. 3. This claim is for: compensation; medical benefits; penalties (under § ________________); other __________________________________________________________. 4. Do you contend or concede that: (a) The LHWCA applies to this claim. Yes No (b) At the time of the alleged injury, an employer-employee relationship existed between Claimant and Employer. Yes No (c) Claimant has suffered an injury or disease. Yes No (d) The alleged injury or disease arose out of and in the course of claimant’s employment. Yes No (e) The claim was timely noticed; timely filed; • • untimely filed. untimely noticed; (f) Claimant is/was entitled to compensation Yes No; medical benefits (g) Employer/Carrier is currently providing: compensation medical benefits (h) Claimant has reached maximum medical improvement. No; Yes No Yes Yes No No Yes, on ________________. (i) Claimant has outstanding medical bills. No; Yes to _______________________________ $ ________________ _______________________________ _________________ _______________________________ _________________ American LegalNet, Inc. www.FormsWorkflow.com 5. Are nature and extent of disability disputed? 6. Is Claimant now working? No; Yes Yes No in his usual employment started on ____________ ; in alternative employment started on ____________ . 7. You contend or concede that claimant is now able to do: his regular pre-injury work without loss of earnings; alternative work; no work. 8. You contend or concede that the alleged injury or disease is unscheduled; is a scheduled injury which caused a ______ % loss/loss of use of ___________________ ; the injury caused disability which was/is: permanent total from ________________ to __________________ temporary total from ________________ to __________________ permanent partial from ________________ to __________________ temporary partial from ________________ to __________________ 9. You contend or concede that Claimant’s average weekly wage when injured was $ _____________ under § 10 subsection ________ , and that his retained weekly earning capacity is: zero; $ _______ based on his current earnings labor market survey(s) other facts 10. Is Special Fund relief sought? conceding entitlement; No; Yes asserting absolute bar; If Yes, is the Director denying entitlement on the grounds of no pre-existing disability disability not manifest to employer contribution requirement not met 11. Set forth below or on separate page(s) other contentions, issues or ultimate facts which you will present at trial (e.g. last responsible employer; § 33(g); collateral estoppel; credits; etc.), and succinctly brief any novel legal questions. 12. Estimated total trial time: DATE: _________________ _______ day(s) _______ hours /s/ ________________________________________________ __________________________ -2- Counsel For _____________________ (REV 08/99) American LegalNet, Inc. www.FormsWorkflow.com