Fill and Sign the Petition for Hearing Industrial Injury Montana Form

(Name, Address, Phone Number) ____________________________________ ____________________________________ ____________________________________ ____________________________________ IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA WCC NO. ___________________ (leave blank) _____________________________________ Petitioner vs. ______________________________________ Respondent/Insurer. PETITION FOR HEARING (Industrial Injury) As set forth in ARM 24.5.301 petitioner alleges: 1. That on _______________, ____, petitioner suffered an industrial injury arising out of and in the course and scope of her/his employment with ___________________________________________________________ in ________________________ County, Montana. Petitioner injured her/his _________________ when: ________________________________________________________________ ___ ___________________ ________________________________________________________________ _______________________ ________________________________________________________________ ____________________. 2. At the time of the injury, petitioner's employer was enrolled under Compensation Plan ______of the Workers' Compensation Act and its insurer is________________________________________________________. 3. A dispute exists between the parties. Explain in detail the nature of the dispute. (Use additional pages if necessary.) ________________________________________________________________ ________________________________________________________________ _____________ ________________________________________________________________ _____________________ ________________________________________________________________ _____________________ 4. Petitioner has exchanged all available pertinent medical records relating to the injury with the defendant and will continue to do so. 5. Check the appropriate paragraph below: ___ a. The parties have made an effort to resolve this dispute but have been unable to do so, and therefore a dispute exists which requires resolution by this Court. (For injuries occurring before July 1, 1987.) ___ b. The mediation procedure set forth in the Workers' Compensation Act has been complied with. (For injuries occurring after July 1, 1987.) * 6. The following is a list of individuals who are potential witnesses for petitioner in this matter: Name and Address General Subject Matter of Testimony ________________________________________________________________ ____________________ ________________________________________________________________ ____________________ ________________________________________________________________ ____________________ * 7. The following is a list of written documents relating to this case which may be introduced as evidence by petitioner: ________________________________________________________________ _____________________ ________________________________________________________________ _____________________ ________________________________________________________________ _____________________ WHEREFORE , petitioner respectfully prays that this petition be set for hearing and that the following relief be granted. (Explain what you want the Court to decide.) 1) ________________________________________________________________ __________________ 2) ________________________________________________________________ __________________ 3) ________________________________________________________________ __________________ DATED this _____ day of _________________, 200_. _______________________________ Petitioner * If additional space is needed, please attach sheet to this petition for hearing.