Free PETITION FOR TRIAL FORM - Montana

(Name, Address, Phone Number)

____________________________________ ____________________________________ __________________________________ ____________________________________ IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA _____________________________________ ) Petitioner ) vs. ) ) _____________________________________ ) Respondent/Insurer.

WCC No.

PETITION FOR HEARING
(OCCUPATIONAL DISEASE)

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. ___ a. Check the appropriate paragraph below: 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.)

*6. The following is a list of individuals who are potential witnesses for petitioner in this matter: Name and Address General Subject Matter of Testimony

* 7. The following is a list of written documents relating to this case which may be introduced as evidence by petitioner:

WHEREFORE, petitioner respectfully prays that this petition be set for hearing and that the following relief be granted. (Explain what you want the Court to decide.) 1) ____________________________________________________________________ 2) ____________________________________________________________________ 3) _____________________________________________________________________ DATED this _____ day of _________________, 200__. _______________________________________ Petitioner

* If additional space is needed, please attach sheet to this PETITION FOR HEARING.

Petition for Hearing (Occupational Disease) - Page 2

WCC (3/00)