Fill and Sign the Request for Cross Examination Alaska Department of Labor Form

ALASKA DEPARTMENT OF LABOR Alaska Workers’ Compensation Board P.O. Box 25512 Juneau, Alaska 99802-5512 Request for Cross-Examination AWCB Case Number Instructions: This form is to be filed to request cross-examination of the author of any report listed on a “Medical Summary” or any nonmedical document. To be used when you file an “Affidavit of Readiness for Hearing,” an “Affidavit of Opposition,” or a “Medical Summary” or within 10 days after another party files a “Medical Summary.” 1. Employee’s Name (Last, First, Middle Initial) 2. Insurer Claim No. 3. Date of Injury 4. Address5. Social Security Number City State Zip Code Telephone 6. Date of Birth 7. Employer8. Insurer/Adjusting Company 9. Address10. Address City State Zip Code Telephone City State Zip Code Telephone I REQUEST THE OPPORTUNITY TO CROSS-EXAMINE THE FOLLOWING WITNESSES FOR THE REASONS STATED: 11. Date of Medical Summary 12. Medical Report Date 13. Reason Cross-Examination is Requested (Be Specific) Prepared By Report Author a. b. c. d. e. a. b. 14. Nonmedical Document Date 15. Document Author 16. Reason Cross-Examination is Requested (Be Specific) Document Description 17. Name of Person Submitting Request (Print or Type) 18.Signature 19. AddressCity State Zip Code Telephone 20. PROOF OF SERVICE: I certify that on the date in #23 below I mailed/delivered a true and correct copy of this request to the following (request will be returned with no action if all parties are not served): a.oThe employee in #1 above at the address in #4 b.oThe employer in #7 above at the address in #9. c.oThe insurer in #8 above at the address in #10. d.oOther (state name and address): NAMEADDRESS NAMEADDRESS 21. Name of Person Serving Request 22. Signature 23. Date Served 74 Form 07-6174 (1/94)