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

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(Name, Address, Phone Number)
____________________________________
____________________________________
__________________________________
____________________________________
IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA
_____________________________________ )
Petitioner
)
WCC No.
vs.
)
PETITION FOR HEARING
)
_____________________________________ )
(OCCUPATIONAL DISEASE)
Respondent/Insurer.
As set forth in ARM 24.5.301 petitioner alleges:
1.
That on _______________, ____, petitioner became aware of an occupational
disease arising out of or contracted in the course and scope of her/his employment with
_______________________________________
in
________________________
County, Montana. Petitioner suffers from the following disease:_________________
__________________________________________ which originated through employment
as follows: _____________________________________________________________
.
2.
At the time of the occupational disease petitioner's employer was enrolled under
Compensation Plan No. _________ of the Workers' Compensation Act and its insurer is
.
3.
A dispute exists between the parties. Explain in detail the nature of the dispute.
(Use additional pages if necessary.)
.
4.
Petitioner has exchanged all available pertinent medical records relating to the
occupational disease with the respondent and will continue to do so.
5.
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.)

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