Before the WORKERS' COMPENSATION BOARD State of Oregon In the Matter of the Compensation of Request for Hearing and Specification of Issues Name Address Date of Injury Claim # (only one claim number per form) Phone # WCD File # Claimant's Attorney Oregon State Bar Number Employer Address Attorney Firm Address Insurer Address Phone # Parties must notify WCB of any address changes A hearing is requested for the reason(s) checked below: A DENIAL (date) N ORDER ON RECONSIDERATION attach copy B Compensability - complete claim denial Y Classification (disabling/nondisabling) X Partial denial after a claim acceptance I Premature closure Z Challenge to notice of acceptance D Substantive temporary disability V Worker noncooperation Period sought K Aggravation H Permanent partial disability L Responsibility G Permanent total disability C Medical services Q OTHER (Explain and cite ORS) P M NONCOMPLYING EMPLOYER ORDER O TEMPORARY DISABILITY DIRECTOR'S ORDER attach copy R Rate S PENALTY (Cite ORS) D Procedural entitlement T ATTORNEY FEE (Cite ORS) Period sought W COSTS U TEMPORARY DISABILITY OFFSET • INTERPRETER WILL BE NEEDED - Language: • The amount in controversy is LESS than $1000. • All day is required for hearing. • Stress claim (Such claims will be set for all day unless otherwise requested) • Compensation stayed (Employer/insurer appeal of WCD Reconsideration Order) • Please consolidate this request for hearing with the following pending Attorney/Claimant Claimant Insurer/Processing Agent Employer DCBS Yes No Yes No Yes No Yes No Yes No ______ _______________________________________________________ Signature of Requester Request by No ___________________ Date NOTICE TO OPPOSING PARTY: The requester demands copies of all medical reports and all other documents pertaining to this claim, whether or not the requesting party intends to rely on them at hearing. Date Received case(s) regarding this claim or claimant: WCB Case No(s) Yes 438-342(6/08WCB) American LegalNet, Inc. www.FormsWorkflow.com