Free Workers' Compensation Docketing Statement - West Virginia

SUPREME COURT OF APPEALS OF WEST VIRGINIA WORKERS ' COMPENSATION DOCKETING STATEMENT
Petitioner: _______________________________________ Counsel: _________________________________________ Respondent: _____________________________________ Counsel: ________________________________________

Claim No.: ______________________ Workers' Compensation Appeal Board No.: ___________________________ Date of Injury/Last Exposure:________________________ Date Claim Filed: _________________________________

Date(s) of Workers' Compensation Division Order(s):_____________________________________________________ Date of Office of Judges Order: _____________________ Date of Workers' Compensation Appeal Board Order Appealed from: ________________________________________

CLAIMANT I NFORMATION :
Claimant's Name: _________________________________________________________________________________ Nature of Injury:__________________________________________________________________________________ Age: ___________________________________________ Occupation: ____________________________________ Education (highest): ______________________________ No. of Years: ___________________________________

Date of Last Employment: _________________________________________________________________________

Other Claim Nos.:________________________________ Status: _________________________________________ (Attach a separate sheet if necessary) Are there any related petitions currently pending before the Supreme Court? Yes No (If yes, cite the case name and the manner in which it is related on a separate sheet.) Are there any other petitions related to this claimant which have been decided by the Supreme Court? Yes No (If yes, cite the case name, docket number, decision, and the manner in which it is related on a separate sheet.) Type of issue:
TTD (Temporary Total Disability) Medical Benefits Occupational Disease PPD (Permanent Partial Disability) Occupational Pneumoconiosis Death or Widow Benefits PTD (Permanent Total Disability) Occupational Hearing Loss Other

F OR S UPREME C OURT U SE O N L Y I vote: GRANT [ ] REFUSE [ ]

SUPERVISING JUSTICE'S VOTE ORAL PRESENTATION [ ]

Signature: _________________________________ Comments:

Date:________________________________

F OR S UPREME C OURT U SE O N L Y I vote: GRANT [ ] REFUSE [ ]

REVIEWING JUSTICE'S VOTE ORAL PRESENTATION [ ]

Signature: _________________________________ Comments:

Date:________________________________

Revised 9/26/97