Fill and Sign the Affidavit of Readiness for Hearing Alaska Department of Labor Form

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board 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 re\ quest 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 fu\ lly 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 “Me\ dical Summary” to date. III. Mail this affidavit to the address of the city where you want the h\ earing held. 2. Date Received (Board Use Only) 3. Date of Injury 1. Employee's Name (Last, First, Middle Initial) 4. Address 5. Social Security Number 6. Date of Birth CityStateZip Code Telephone 8. Employer 10. Employer Address City StateZip Code Telephone 7. Insurer/Adjusting Company 9. Insurer Address City Zip Code State 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 necessar\ y discovery, obtained necessary evidence, and am fully prepared for a he\ aring on the issues set forth in the Workers' Compensation Claims(s) OR Petition(s) Dated 13. Please Schedule (Choose one): Location: 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. Oral Hearing Hearing on the Record Hearing on the Record with Briefs Anchorage 3301 Eagle Street, Suite 304 Anchorage AK 99503 Fairbanks 675 7th Avenue, Station K Fairbanks, AK 99701-4593 Juneau P.O. Box 115512, Juneau AK 99811-5512 1111 W 8th St Rm 307, Juneau AK 99801 14. Attorney Name and Firm Name (If represented) 15. Telephone 16. Attorney Address CityStateZip Code 17. Name of Affiant (Print or Type) 18. Signature (Sign in Front of Notary) 19. Affiant Address CityStateZip Code Telephone NOTARY PUBLIC ______________________________________________________ Notary Public in and for the State of My Commission Expires: Subscribed and sworn to me this day of , 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 (affida\ vit will be returned with no action if all parties are not served): a. The employee in #1 above at the address in #4. b. The employer in #8 above at the address in #10. c. The insurer in #7 above at the address in #9 d. Other (name and address below): 21. Name of Person Serving Affidavit 22. Signature 23. Date If a party receiving this affidavit is not ready for hearing, the party m\ ust serve on the other parties and file with the Division of Workers' Co\ mpensation, at the office checked in box #13, an Affidavit of Opposition within 10 days of the “Date Served” shown in box #23. I\ f no Affidavit of Opposition is filed timely, a hearing will be set with\ in 60 days. Form 07-6107 (Rev 04/2011)