CASE NAME : CASE NO : OWCP NO: STIPULATIONS 1. The LHWCA, 33 USC 901 et seq., as amended, applies to this claim. 2. The injury(ies) occurred on .3. The injury occurred at .4. The injury arose out of and in the course of the workers employment with the Employer. 5. There was an Employer/Employee relationship at the time of injury(ies). 6. The Employer was timely notified of the injury(ies). 7. The claim for benefits was timely filed. 8. The Notice of Controversion was timely filed. 9. The Informal Conference was conducted on . 10. The workers average wee kly wage at time of inury(ies) wasj $ .11. Compensation has been paid as follows (specify whether TTD, TPD, PTD or PPD*): WEEKLY COMPENSATION TYPE * DATES RATE a. from to at $ b. from to at $ c. from to at $ d. from to at $ .12. Medical benefits have been paid in the total amount of $ 13. The worker has been disabled as follows (specify whether TTD, TPD, PTD or PPD*): TYPE * DATES a. from to b. from to c. from to d. from to American LegalNet, Inc. www.USCourtForms.com>>>> 214. The worker reached maximum medical improvement on . 15. The worker returned to his usual job as a on .16. The worker has not returned to his usual job. 17. The worker has engaged in alternative employment as follows: EMPLOYER DATES PAY RATE a. from to at $ b. from to at $ 18. OTHER a. b. c. d. 19. Unresolved issues to be adjudicated: a. b. c. d. e. f. g. FOR THE CLAIMANT FOR THE EMPLOYER FOR THE DIRECTOR FOR THE CARRIER American LegalNet, Inc. www.USCourtForms.com