Free K-WC 139 (Rev. 8-98) - Kansas

Re: Vs: and Docket No.

Clmt Atty Resp Atty Fund Atty Date of Hearing (Ks. Adm. Reg. 51-3-8)

PRE-TRIAL STIPULATIONS
Notice of Hearing Objections? Form? Service?

Questions to Claimant 1. In what county is it claimed that Claimant met with personal injury by accident? May it be heard in this County? Yes No

2. Upon what date is it claimed that Claimant met with personal injury by accident?

Questions to Respondent 3. Does Respondent admit Claimant met with personal injury by accident on the date alleged? 4. Does Respondent admit Claimant's alleged accidental injury "arose" out of and in the course of employment? 5. Does Respondent admit notice? 6. Does Respondent admit the relationship of employer/employee existed on the date of the alleged accident? 7. Does Respondent admit the parties are covered by the Kansas Workers Compensation Act? 8. Does Respondent admit claim was made? 9. Did Respondent have an Insurance Carrier on the date of the alleged accident? Name of Company:

Admitted

Denied

Admitted Admitted

Denied Denied

Admitted

Denied

Admitted Admitted Yes No

Denied Denied

Questions to Both Parties 10. Is there an agreement on the average weekly wage? Yes No $

If no agreement, then parties are expected to provide me with this information within 30 days of this date. If not received within that time, the Respondent will be bound by Claimant's testimony.

K-WC 139 (Rev. 8-98)

11. Has any compensation been paid? Temporary Total Total Amount: Number of Weeks: Dates: Rate: Agreed: Yes No

Yes

No Temporary Partial Total Amount: Number of Weeks: Dates: Rate:

12. What additional dates does Claimant claim temporary total for?

13. Has any medical or hospital treatment been furnished? Yes (Read into record amount paid and to whom paid) 14. Does Claimant claim hospital or medical expense for: Reimbursement: Yes No (Read into record or submit by letter within 30 days) Additional: Yes No (Read into record or submit by letter within 30 days) Future: Physical Restoration: Yes Yes No No Amount: Total $

No

Amount:

15. Is claim made by Claimant for unauthorized medical? 16. Is nature and extent of disability an issue: Yes No

17. Is there an agreement upon a functional impairment rating? 18. Is there a desire on the part of either party to have the Claimant referred to Vocational Rehabilitation for retraining? Yes No 19. Is the Workers' Compensation Fund to be impleded as an additional party? Yes 20. Fund's liability? No

21. What evidence is scheduled by the Claimant? By the Respondent? Facts: Terminal Dates: Claimant: Respondent: Fund