Fillable Form 07-6107 - Affidavit Of Readiness For Hearing printable pdf download

AWCB Case Number:

AFFIDAVIT OF READINESS

ALASKA DEPARTMENT OF LABOR &

WORKFORCE DEVELOPMENT

FOR HEARING

Alaska Workers' Compensation Board

P.O. Box 115512, Juneau AK 99811-5512

Before you complete and submit this form, read carefully. Use only to request a hearing after an answer has been filed or at least 20 days after a Workers' Compensation Claim or petition was

served, whichever comes first. Do not submit this form unless you are fully prepared for a hearing. Before your case will be set for a hearing, you must comply with the following instructions:

I. Attach a completed “Medical Summary” (Form 07-6103) if you have new reports since your last Medical Summary, except as provided in 8 AAC 45.052.

II. Attach a “Request for Cross-Examination” if you wish to cross-examine the authors of any medical reports listed on any party's “Medical Summary” to date.

III. Mail this affidavit to the address of the city where you want the hearing held.

2. Date Received (Board Use Only)

1. Employee's Name (Last, First, Middle Initial)

3. Date of Injury

4. Address

5. Social Security Number

6. Date of Birth

City

State

Zip Code

Telephone

7. Insurer/Adjusting Company

8. Employer

9. Insurer Address

10. Employer Address

City

State

Zip Code

Telephone

11. Is Employee now receiving compensation payments?

City

State

Zip Code

Telephone

Weekly Compensation Rate $

Yes

12. Having first been duly sworn, I state that I have completed necessary discovery, obtained necessary evidence, and am fully prepared for a hearing on the issues set forth in

the

Petition(s) Dated

Workers' Compensation Claims(s) OR

Oral Hearing

Hearing on the Record

Hearing on the Record with Briefs

13. Please Schedule (Choose one):

Anchorage

Fairbanks

Juneau

Location:

3301 Eagle Street, Suite 304

675 7th Avenue, Station K

P.O. Box 115512, Juneau AK 99811-5512

Anchorage AK 99503

Fairbanks, AK 99701-4593

1111 W 8th St Rm 307, Juneau AK 99801

I requested an oral hearing and expect

witnesses (not including witnesses who will testify by deposition), including

medical witnesses, and estimate

the time required for my portion of the hearing will be

hours.

14. Attorney Name and Firm Name (If represented)

15. Telephone

16. Attorney Address

City

State

Zip Code

17. Name of Affiant (Print or Type)

18. Signature (Sign in Front of Notary)

19. Affiant Address

City

State

Zip Code

Telephone

20. PROOF OF SERVICE (Required): I certify that on the date in #23 below, I mailed

NOTARY PUBLIC ______________________________________________________

a true and correct copy of the above affidavit to the following (affidavit will be returned

Notary Public in and for the State of

with no action if all parties are not served):

a. The employee in #1 above at the address in #4.

b. The employer in #8 above at the address in #10.

c. The insurer in #7 above at the address in #9

d. Other (name and address below):

My Commission Expires:

Subscribed and sworn to me this

day of

21. Name of Person Serving Affidavit

23. Date

22. Signature

f a party receiving this affidavit is not ready for hearing, the party must serve on the other parties and file with the Division of Workers' Compensation, at the office checked in box #13, an Affidavit of

Opposition within 10 days of the “Date Served” shown in box #23. If no Affidavit of Opposition is filed timely, a hearing will be set within 60 days.

Form 07-6107 (Rev 04/2011)