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Sample Hearing Information Sheet

(Note: This is not an official VWC form or document, and is merely an example of a type of document which has been utilized in the past. It may not be suitable for your situation and no warranty is made regarding its reliability.)

 

Case Outline

Case Name:_________________________ v. _____________________________

V.W.C. File No.:____________________________

Claimant’s Attorney: 

Employer’s and Insurer’s Attorney:

(Claimant’s Claim for Benefits)(Employer’s Application) filed on _______________alleges:

______Injury by Accident:

  Part(s) of Body Injured:______________________________

  Date of Accident:____________________

______Occupational Disease:

  Disease:______________________ 

  Date of Communication:_________________________

  Communication by whom:____________________________

  Date claimant last worked for defendant employer________________

______Change in Condition:

  TTD/TPD/PPD:_____________________________________

  Medicals:__________________________________________

______Other:_____________________________________________

_______________________________________________________________

Relief Sought:_____TTD_____TPD_____PPD_____MEDS

                          _____Suspension/Termination of Comp._______________________

                          _____Other:____________________________________

DATES:________________ thru__________________ RTW DATES:____

  ________________ thru__________________ 

  ________________ thru__________________ 

Defenses:______________________________________________________________

______________________________________________________________________

______________________________________________________________________

Stipulations: Average Weekly Wage:__________________

Period(s) of Disability:__________________________________________

Treating Physician:___________________________________

Date(s) released to light duty:____________________________________________

Date(s) released to regular duty:__________________________________________

Other Stipulations:_________________________________________

Claimant’s Witnesses:

 

Employer's Witnesses:

 

Prior Award(s):________________________________________________

 

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