Fill and Sign the Wc 77 Application for Hearing Hawaii Department of Labor Form

Visit our W ebsi te at www.ha waii.gov/l abor fo r ALL inter active an d do wnl oadabl e forms. (Rev. 10/0 5) STATE OF HAWAI I DEPARTMENT OF LABOR AND INDUSTRIAL RELAT IONS DISA BILITY COMPENSA TION DIVIS ION Pr ince ss Keel ikolan i Buil ding, 830 Punchbowl Street, Room 209, Honol ulu, Ha wa ii 96813 INSTRUCTION SHEET FOR FORM W C-77a RESPONSE TO APPLI CATION FOR HEARI NG Instructi ons Important Noti ce : Upon recei pt of the Appli cati on of Heari ng, the adverse part y m ay fil e a “RESPONSE TO T HE APPLICATION FOR HEA RING” wi th the Di rector and shal l send a copy to al l parties. Please co mpl etely fill out the WC-77a RESP ONSE TO APPLICATION FOR HE ARING FORM. Compl etion of th is form wi ll expe dite resol ution of issu es of co ntro versy i n a fai r and j udi cious manne r. The De livery In formation secti on bel ow li sts vari ou s d elivery opti ons. Please sel ect the mo st con venient method an d submi t the co mpl eted form accordi ngl y. Please rem ember to si gn and date the form before submi tting it. Delivery Informat ion Deli very b y U.S. Ma il, In-Perso n, or vi a Fax Department of Labor an d Industri al Rel ations , Di sabili ty Compensati on Di vision Oahu Kauai Mau i Pri ncess Keel ikolani Bu ilding 830 Pun chb owl Street, Room 209 Hon olulu, Hawai i 96813 Maili ng Addre ss: P.O. Box 376 9 Hon olulu, Hawai i 96812-3 769 Phone: (8 08) 586-916 1 Fax: (8 08 ) 58 6-92 19 3060 Ei wa Street, Ro om 2 02 Lihue, Hawai i 96766 Phone: (8 08) 274-335 1 Fax: (8 08 ) 27 4-33 55 2264 Aup uni Street #2 Wai luku, Hawaii 96793 Phone: (8 08) 984-207 2 Fax: (8 08 ) 98 4-20 71 Haw aii West Ha waii 75 Aupuni Street, Room 1 08 Hilo, Hawai i 96720 Phone: (8 08) 974-646 4 Fax: (8 08 ) 97 4-64 60 Ashikawa Bu ild ing 81-9 90 Hal ekii Street, Roo m 2087 Keal akekua, Ha wai i 96750 If Maili ng, Please M ail to T his Addre ss: P.O. Box 49, Keal akel ua, Ha wai i 96750 Phone: (8 08) 322-480 8 Fax: (8 08 ) 32 2-48 13 Visit our W ebsi te at www.ha waii.gov/l abor fo r ALL inter active an d do wnl oadabl e forms. (Rev. 10/0 5) STATE OF HAWAI I DEPARTMENT OF LABOR AND INDUSTRIAL RELAT IONS DISA BILITY COMPENSA TION DIVIS ION Pr ince ss Keel ikolan i Buil ding, 830 Punchbowl Street, Room 209, Honol ulu, Ha wa ii 96813 FORM W C-77a RESPONSE TO APPLIC ATI ON FOR H EAR IN G Name of R espond ent Address Telep hon e No. ( ) Repr esenti ng ) Case No. ______________________________ (Claimant Name) ) ) Date Of Inj ury _________ _________________ vs. ) ) ) ) (Employ er/Carrier) ) ) ) ) ) RESPONSE TO AP PLIC ATION FOR HEARING I, _______________________________ , above -na me d re spon dent, hereb y respo nd to the Appl icati on for Heari ng fil ed by _________________________ on __________________________ . 1. RESPONSES Re spo nse(s) to stateme nt(s) of the i ssu e(s) as l isted on Ite m num ber 2 o n page 2 of the “Appl icati on for Hea ring” F orm (WC-77) to b e determi ned at the heari ng. REVIEW OF EMPLOYER'S DE NIAL OF HEALTH CARE ____________________________________________________ ________________________________________________________________________\ __________________________ COMPE NSABILITY _______________________________________________________________\ __________________ ________________________________________________________________________\ __________________________ TERMINATI ON OF TEM PORARY TOTAL DISABILITY _________________________________________________\ ____ ________________________________________________________________________\ __________________________ TERMINATI ON OF TEM PORARY PA RTIAL DISABILITY ___________________________________________________ ________________________________________________________________________\ __________________________ PERMANENT DISABILITY ___________________________________________________\ _________________________ ________________________________________________________________________\ __________________________ DISFIGURE MENT _____ ________________________________________________________________________\ _____ ________________________________________________________________________\ __________________________ DEPENDE NT DEATH BENEFITS ______________________________________________________\ ________________ ________________________________________________________________________\ __________________________ Visit our W ebsi te at www.ha waii.gov/l abor fo r ALL inter active an d do wnl oadabl e forms. (Rev. 10/0 5) WC-7 7a RESPO NSE TO APPL ICATION FOR HEARING Page 2 of 2 CONCURRE NT EMPLOY MENT _____ __________________________________________________________________ ________________________________________________________________________\ __________________________ REOPENI NG ______________________________________________________________________\ ________________ ________________________________________________________________________\ __________________________ OTHE R ISSUES _______________________________________________________________\ _____________________ ________________________________________________________________________\ __________________________ 2. WITNESSES Please li st name(s) a nd ad dre ss(e s) of a ll witness(e s) to be pre sented at the hea ring and/or tho se who se test imony wi ll be submi tted vi a a depo sition transcri pt. In the i nterest of j usti ce and fai rness, fail ure to li st the n ames of wi tness(e s) and/o r those who se testi mony wi ll be sub mitted vi a a deposi tion tran scri pt may p reclude wi tnesse s fro m testi fying a t the heari ng and/or sub mitting a deposi tion transcri pt. Name Work Phon e ( ) Home Ph on e ( ) Address Name Work Phon e ( ) Home Ph on e ( ) Address If necessa ry, pl ease l ist an y addi tional names, p hone numbe rs and addresse s of witnesses o n a sep arate sh eet. Name Work Phon e ( ) Home Ph on e ( ) Address 3. SP ECIAL ACCOMMODATIONS Are there an y unusual , emerge ncy o r extenuati ng con ditions that you wo uld li ke the Dep artme nt to consi der in cal endari ng thi s case fo r a heari ng? If ye s, pl ease b riefly expl ain bel ow: _______________ (Date ) (Si gnature of Respon dent) Auxi liary ai ds and se rvi ces are a vailabl e upon requ est. Pl eas e cal l: (808 ) 58 6-9 161; TTY (808) 586-8847; and for neighbor islands, TTY 1-88 8-569 -68 59. A reque st for reasona ble acco mmodati on(s) sh ould be made no l ater than ten wo rki ng d ays pri or to the ne eded a ccom modati on(s). It is the poli cy of the Depa rtment of Labo r and Ind ustri al Rel ations that no pe rson shal l, on t he basi s of ra ce, col or, se x, mari tal status, reli gion, creed, ethni c ori gin, nati onal ori gin, age, disabi lity, ance stry, arrest/c ourt re co rd, se xual ori enta tion, and Nati onal Guard pa rticipati on, be su bjected to di scri minati on, e xcl ude d from parti cipati on in, or deni ed the ben efi ts of the Dep artme nt’s se rvi ces, prog rams, act iviti es, or em ployment.