Fill and Sign the Department of Labor and Workforce Developmentfrequently Form

PETITION TO DETERMINE COMPENSATION DUE TO INJURED EMPLOYEE To the Industrial Accident Board of the State of Delawa re Sitting in and for County Claimant SS# Claimant Date of Birth vs. Insurance Carrier Case File No. Employer The undersigned petitioner respectfully represents: That the above named claimant and the above named employer have failed to reach an agreement in regard to compensation due said claimant as an employee of said employer. The undersigned therefore prays that your Honorable Board shall, after due notice of the time and place of hearing served on all parties in interest, hear and determine the matter in accordance with the facts and the law and state its conclusions of fact and rulings of law. My signature on this petition is authorization for any doctor, hospital, other health care provider, or State of Delaware Division of Vocational Rehabilitation to supply any and all medical records and reports to the bearer of the original or a copy of this petition regarding any medical condition provided all requests for this information are in writing. Dated this day of A.D. 20 Claimant’s Signature Name of Attorney, if applicable Document Control # A60-07-05-08-12 } INDUSTRIAL ACCIDENT BOARD STATE OF DELAWARE Statement of Facts Upon Failure to Reach an Agreement 1. Name of Employee Address City____________________________ State______________ Zip Telephone Number __________________E-mail (optional) 2. Date of Accident ________________ 3. Place of Accident 4. Name of Employer Employer Contact Name_______________________ E-mail (optional) Address City____________________________ State _______________ Zip Telephone Number _____________________Fax # 5. Name of Insurance Carrier / 3 rd Party Administrator 6. Occupation of employee at the time of accident 7. Describe accident/illness and how it happened 8. List the body part(s)/illness 9. Did employee receive medical, surgical or hospital service? Yes No 10. When was notice of injury given to or received by employer? 11. Give names and addresses of all employers for the last 5 years. If more space is needed, attach a separate sheet. NAME: ADDRESS: 12. State weekly wage when injured 13. State names and addresses of all treating doctors for this claim. If more space is needed, attach a separate sheet. NAME: ADDRESS: 14. State names and address of all other treating doctors for the last 10 years. If more space is needed, attach a separate sheet. NAME: ADDRESS: 15. Give names and addresses and dates of treatment of all hospitals and institutes treating you for this injury. If more space is needed, attach a separate sheet. NAME: ADDRESS: 16. To what extent did injury prevent employee from working and for how long 17. State whether or not employee has fully recovered and if only partially to what extent 18. If employee has resumed work, state a) when and give name of present employer b) what trade or occupation and weekly wages 19. Identify, give description and dates of all previous and subsequent injuries. 20. State any other important facts bearing on the case above presented