Adjournment Or Ready Hold Form

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DIVISION OF WORKERS’ COMPENSATION

Today’s Date:

ADJOURNMENT or READY HOLD FORM

Vicinage & Fax:

Fax/Mail/E-Mail to Court Vicinage and All Other Parties*

AdjReq063016

E-Mail:

If emailing, refer to instructions at bottom of form

Hearing Date:

____________________

Judge

______________________________________

# on Hearing List:

__________

Check One:

Adjournment Request for

________

cycles

Ready Hold for

_____________

(Time)

( Court Reporter Required

Yes

)

CP #:

____________________________

Case Title:

____________________________________________________________

** Use additional pages if there are multiple cases to be adjourned for this Judge’s hearing list

Request by (Name of Attorney & Firm):

__________________________________________________________________________

Counsel for (Check One):

Petitioner or Medical Provider

Respondent

_____ _

Telephone Number:

FAX Number:

_______________________

Reason for Request (Required):

Petitioner to be examined by petitioner’s expert Dr

__________________________________________

__________________

Petitioner to be examined by respondent’s expert Dr.

_________________________________________

__________________

Attorney conflict due to:

______________________________________________________________________________________

Petitioner continuing to receive

Authorized

Unauthorized) medical treatment.

(

Other (Be Specific):

Other Case Parties Notified of this Request:

*In requesting an Adjournment or Ready Hold you are certifying that all parties including co-respondents and, when applicable, the Deputy Attorney General and

Special Counsel for the Uninsured Employers Fund have also received the request.

Requests are to be made as soon as adjournment or ready hold basis is known. Requests are to be received (if mailed, ensure timely receipt) not less than 24 hours of

the scheduled case listing date and time (for Monday lists or Tuesday lists after Monday holiday by 9 am of preceding Friday). Emergent requests (less than 24

hours) require telephone request to judge and parties.

If request is denied, this form will be faxed to your office as indicated below. If denied, you are to notify all parties of the denial.

If Checked, Request is Denied. Denial Reason:

___________________________________________________________

E-Mail Instructions: Send completed document to the email address shown above, with Subject: “Adjournment Req mm/dd/yyyy - Office Name - Judge”