Petition For Hearing (Injury) - Workers' Compensation Court Of The State Of Montana printable pdf download

Petition For Hearing (Injury) - Workers' Compensation Court Of The State Of Montana

(Name, Address, Phone Number)

____________________________________

IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA

_____________________________________)

Petitioner

)

WCC No.

vs.

)

PETITION FOR HEARING

)

_____________________________________,)

(INJURY)

Respondent/Insurer.

As set forth in ARM 24.5.301 petitioner alleges:

That on _______________, ____, petitioner suffered an industrial injury arising out

of and in the course of her/his employment with ___________________________

______________________________________ in ________________________ County,

Montana. Petitioner injured her/his __________________________________________

when _________________________________________________________________

_____________________________________________________________________.

At the time of the injury, petitioner's employer was enrolled under Compensation

Plan No. ______ of

the

Workers' Compensation Act and its insurer is

_____________________________________________________________________.

A dispute exists between the parties. Explain in detail the nature of the dispute.

(Use additional pages if necessary.)

________________________________________________________________________

_______________________________________________________________________

Petitioner has exchanged all available pertinent medical records relating to the injury

with the respondent and will continue to do so.

Check the appropriate paragraph below:

___ a.

The parties have made an effort to resolve this dispute but have been unable

to do so, and therefore a dispute exists which requires resolution by this

Court.

(For injuries occurring before July 1, 1987.)

___ b.

The mediation procedure set forth in the Workers' Compensation Act has

been complied with.

(For injuries occurring on or after July 1, 1987.)

Petition For Hearing (Injury) - Workers' Compensation Court Of The State Of Montana