U.S. Department of Labor Office of Administrative Law Judges 50 Fremont Street, Suite 2100 San Francisco, CA 94105 Case Caption and No. ___________________________________________________ ______________ PRETRIAL STATEMENT of: Claimant __________________________________________ Director, OWCP Respondent __________________________________________ 1. Briefly summarize, below or on attached sheet, the facts or circumst ances you contend gave rise to this claim, and describe the nature of the claimed injury or dis ease. 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 relat ionship 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 claimants employment. Yes No (e) The claim was timely noticed; untimely noticed; timely filed; untimely filed. (f) Claimant is/was entitled to compensation Yes No; m edical benefits Yes No (g) Employer/Carrier is currently providing: compensation Yes No medical benefits Yes No (h) Claimant has reached maximum medical improvement. No; Yes, on ________________. (i) Claimant has outstanding medical bills. No; Yes to _______________________________ $ ________________ ________________ _______________ _________________ ________________ _______________ _________________ American LegalNet, Inc. www.USCourtForms.com>>>> 25. Are nature and extent of disability disputed? Yes No 6. Is Claimant now working? No; Yes in his usual empl oyment 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 Claimants average weekly wage when injured was $ _____________ under 10 subsection ________ , and that his retained weekly ea rning capacity is: zero; $ _______ based on his current earnings labor market survey(s) other facts 10. Is Special Fund relief sought? No; Yes If Yes, is the Director conceding entitlement; asserting absolute bar; denying entitlement on the grounds of no pre-existing disability disability not manifest to employer contribution requirement not met11. 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: _______ day(s) _______ hours DATE: _________________ /s/ _______________________________________ _________ __________________________ Counsel For _____________________ - 2 - (REV 08/99) American LegalNet, Inc. www.USCourtForms.com