Free Request for Hearing Form pdf format - Oregon

Before the WORKERS' COMPENSATION BOARD State of Oregon In the Matter of the Compensation of
Name Address Phone # WCD File # Claimant's Attorney Oregon State Bar Number Attorney Firm Address Employer Address Insurer Address Phone #

Request for Hearing and Specification of Issues
Date of Injury Claim #
(only one claim number per form)

Parties must notify WCB of any address changes
A hearing is requested for the reason(s) checked below: A DENIAL (date) B Compensability - complete claim denial X Partial denial after a claim acceptance Z Challenge to notice of acceptance V Worker noncooperation K Aggravation L Responsibility C Medical services M NONCOMPLYING EMPLOYER ORDER O TEMPORARY DISABILITY R Rate D Procedural entitlement
Period sought

N ORDER ON RECONSIDERATION I Premature closure D Substantive temporary disability
Period sought

attach copy

Y Classification (disabling/nondisabling)

H Permanent partial disability G Permanent total disability Q P S T W U OTHER (Explain and cite ORS) DIRECTOR'S ORDER attach copy PENALTY (Cite ORS) ATTORNEY FEE (Cite ORS) COSTS TEMPORARY DISABILITY OFFSET Yes Yes Yes Yes Yes Yes No No No No No No

· INTERPRETER WILL BE NEEDED - Language: · The amount in controversy is LESS than $1000. · All day is required for hearing. · Stress claim (Such claims will be set for all day unless otherwise requested) · Compensation stayed (Employer/insurer appeal of WCD Reconsideration Order) · Please consolidate this request for hearing with the following pending
case(s) regarding this claim or claimant: WCB Case No(s) ______ _______________________________________________________ Signature of Requester Request by Attorney/Claimant Claimant Insurer/Processing Agent Employer DCBS

___________________ Date

NOTICE TO OPPOSING PARTY:

The requester demands copies of all medical reports and all other documents pertaining to this claim, whether or not the requesting party intends to rely on them at hearing.

438-342(6/08WCB)

Date Received