Before the WORKERS' COMPENSATION BOARD State of Oregon In the Matter of the Compensation of *** RESPONSE TO ISSUES *** WCB Case No: Claimant's Name Claim No: (N) Reconsideration Order Date: (A) Denial Date: In response to the issues raised by the claimant, the insurer or self-insured employer: ADMITS DENIES That claimant sustained a work-related accidental injury or occupational disease. (BX) (V) That claimant cooperated with the claims investigation. (Z) That a condition has been incorrectly omitted (scope of acceptance). (OD) That claimant is entitled to additional temporary disability. (HG) That claimant is entitled to additional permanent disability. (I) That the claim was prematurely closed. (Y) That the claim should be classified as disabling. (K) That claimant sustained an aggravation of the injury/disease on (date) (L) That the employer is responsible. (M) That the parties were subject to the Workers' Compensation Act. (P) Director's Order Date: (Q) Other - Explain & Cite ORS: (R) That the claimant was paid temporary disability at an incorrect rate. (S) That claimant is entitled to a penalty for (T) Attorney Fees - Cite ORS: (W) Costs (U) Temporary Disability Offset. The Insurer or Self-Insured Employer hereby Cross-Appeals and Contends: That the award of permanent disability is excessive. That the award of temporary disability is excessive. Entitlement to an offset for an overpayment of temporary disability benefits in the amount of $ The responding party demands copies of all medical reports and all other documents pertaining to this claim, whether or not the requesting party intends to rely upon them at hearing. INTERPRETER WILL BE NEEDED. Yes No LANGUAGE For: Dated , 20 By: Response.doc (REV 01/09) OSB #: American LegalNet, Inc. www.FormsWorkFlow.com