Free ALASKA DEPT OF LABOR & WORKFORCE DEVELOPMENT - Alaska

ALASKA DEPT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Division P.O. Box 115512 Juneau, AK 99811-5512

Affidavit of Readiness for Hearing

AWCB Case Number:

Before you complete and submit this form, read carefully. Use only to request a hearing after an answer has been filed or at least 20 days after a Workers' Compensation Claim or petition was served, whichever comes first. Do not submit this form unless you are fully prepared for a hearing. Before your case will be set for a hearing, you must comply with the following instructions: I. Attach a completed "Medical Summary" (Form 07-6103) if you have new reports since your last Medical Summary, except as provided in 8 AAC 45.052. II. Attach a "Request for Cross-Examination" if you wish to cross-examine the authors of any medical reports listed on any party's "Medical Summary" to date. III. Mail this affidavit to the address of the city where you want the hearing held.

1. Employee's Name (Last, First, Middle Initial) 4. Address City 8. Employer 10. Employer Address City State Zip Telephone State Zip Telephone

2. Date Received (Board Use Only) 5. Social Security Number 7. Insurer/Adjusting Co 9. Insurer Address City State Zip

3. Date of Injury 6. Date of Birth

Telephone

11. Is Employee now receiving compensation payments? Yes No Weekly Compensation Rate $ 12. Having first been duly sworn, I state that I have completed necessary discovery, obtained necessary evidence, and am fully prepared for a hearing on the issues set forth in the Workers' Compensation Claim(s) or Petition(s) dated 13. Please Schedule (Choose One) Location: Oral Hearing Hearing on the Record Hearing on the Record with Briefs Fairbanks 675 7th Ave., Station K Fairbanks, AK 99701-4593 Juneau PO Box 115512 1111 W 8th St., Rm. 307 Juneau, AK 99811-5512

Anchorage PO Box 107019 3301 Eagle St Ste 304 Anchorage, AK 99510-7019

I requested an oral hearing and expect witnesses (not including witnesses who will testify by deposition), including medical witnesses, and estimate the time required for my portion of the hearing will be hours. 14. Attorney's Name and Firm Name (If represented) 16. Attorney's Address 17. Name of Affiant (Print or Type) 19. Affiant Address NOTARY PUBLIC Notary Public in and for the State of City State 15. Telephone No. Zip Telephone

18. Signature (sign in front of Notary) City State Zip Telephone

20. PROOF OF SERVICE (required): I certify that on the date in #23 below, I mailed a true and correct copy of the above affidavit to the following (affidavit will be returned with no action if all parties are not served): a. b. c. d. The employee in #1 above at the address in #4. The employer in #8 above at the address in #10. The insurer in #7 above at the address in #9. Other (name and address below)

21. Name of person serving affidavit My Commission Expires: Subscribed and sworn to me this day of ,20 22. Signature 23. Date

If a party receiving this affidavit is not ready for hearing, the party must serve on the other parties and file with the Division of Workers' Compensation, at the office checked in box #13, an Affidavit of Opposition within 10 days of the "Date Served" shown in box #23. If no Affidavit of Opposition is filed timely, a hearing will be set within 60 days.

Form 07-6107 (Revised 05/06)