PETITION FOR PHYSICAL EXAMINATION OR EXPERTDEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION INTERVIEW OF EMPLOYEE (SECTION 314) EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone INJURY INFORMATION Provide the following information if Employer has accepted liability for this injury: Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease DATE OF INJURY 003WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN VS. INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim #NOTICE TO EMPLOYEE: Employer must indicate whether 223physical examination224 or 223expert interview224 is required by checking the appropriate boxes. . 1.The insurer/employer alleges that it requested the employee to submit to a physical examination expert interview by, HEALTH CARE PROVIDER222S/EXPERTS NAME AND ADDRESS AND FIELD OF SPECIALTY OR EXPERTISE for the purposes of on , and the employee refused or failed IME/IRE/EXPERT INTERVIEW MM DD YYYY to appear at such examaination or interview. date of last physical examination of the employee by the health care provider chosen by the insurer/employer or- - expert interview of the employee by the expert chosen by the insurer/employer was on . DD YYYY 3.If the petition is for the purpose of an IRE, the date of the request was on .MM DD YYYY 4.003 Wherefore the insurer/employer petitions the Workers222 Compensation Judge to order the employee to submit to002 a physical examination 002 an expert interview by or by such health care HEALTH CARE PROVIDER222S/EXPERTS NAME provider(s)/expert(s) as may be designated by the Workers222 Compensation Judge at such time and place as may be set and determined . IME/IRE/EXPERT INTERVIEW -- MM -- Notice of Compensation Payable dated Supplemental Agreement dated Other datedPetition dated MM DD YYYY --MM DD YYYY --MM DD YYYY --MM DD YYYY -- American LegalNet, Inc. www.FormsWorkFlow.com 002002002002002002003002 002 002 CLAIMANT SERVED PLEASE ENTER MY APPEARANCE FOR PETITIONER COUNSEL FOR RESPONDENT (if known) Attorney222s name Attorney222s name PA Attorney ID number PA Attorney ID number Firm name Address Address City/Town State ZIP Firm name Address Address City/Town State ZIP TelephoneTelephonePetitioner or representative222s signature --Date of petition MM DD YYYY Petitioner or representative222s name (typed/printed)002002002002002003 *499*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com