Request For Hearing Page 2
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28. Petitioner claims to be entitled to
(Attach a sheet if necessary to list additional periods.)
TTD period(s):
representing _______ weeks.
______________________________________________________ ,
First day of lost time through Last day of lost time
Respondent agrees ____ disputes ____ and claims
_______________________________________________
TPD period(s):
representing _______ weeks.
________________________________________________________ ,
First day through Last day
Respondent agrees ____ disputes ____ and claims
_______________________________________________
Maintenance period(s):
representing _______ weeks.
_________________________________________________ ,
First day through Last day
Respondent agrees ____ disputes ____ and claims
_______________________________________________
9. Respondent claims it paid $
in TTD, $
in TPD,
__________________
__________________
$
in maintenance, $
in nonoccupational indemnity disability benefits,
_________________
_________________
and $
in other benefits, for which credit may be allowed under §8(j) of the Act.
__________________
Petitioner agrees ____ disputes ____ and claims
___________________________________________________
10. The nature and extent of the injury is ____
is not ____ in dispute.
11. Petitioner claims to be entitled to penalties/attorney’s fees under §19(k) ___ §19(l) ___ and/or §16 ___.
Petitioner has ____
has not ____ filed a penalty petition.
12. A petition for attorney’s fees by a former attorney is ____ is not ____ pending. Petitioner’s attorney has
notified the former attorney of the date of this hearing.
13. Other issues, not listed above, are:
______________________________________________________________________
14. S
. Both parties agree that if either party files a Petition for Review of
TENOGRAPHIC STIPULATION
Arbitration Decision and orders a transcript of the hearings, and if the Commission's court reporter does not
furnish the transcript within the time limit set by law, the other party will not claim the Commission lacks
jurisdiction to review the arbitration decision because the transcript was not filed timely.
A written decision, including findings of fact and conclusions of law, is requested pursuant to Section 19(b).
__________________________________________________
________________________________________________
Date submitted
Name of Respondent's insurance or service company
__________________________________________________
________________________________________________
Signature of Petitioner or Petitioner's attorney
Signature of Respondent or Respondent's attorney
__________________________________________________
________________________________________________
Attorney’s name and IC code #
Attorney’s name and IC code #
__________________________________________________
________________________________________________
Name of law firm
Name of law firm
__________________________________________________
________________________________________________
Street address
Street address
__________________________________________________
________________________________________________
City, State, Zip code
City, State, Zip code
______________________ ___________________________
_____________________ _________________________
Telephone number
Email address
Telephone number
Email address
N
: The arbitration decision will be sent by certified mail to the addresses listed above.
OTE
p. 2
IC9
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