"Petition to Determine Compensation Due to Injured Employee" - Delaware

Petition to Determine Compensation Due to Injured Employee is a legal document that was released by the Delaware Department of Labor - a government authority operating within Delaware.

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Download "Petition to Determine Compensation Due to Injured Employee" - Delaware

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PETITION TO DETERMINE COMPENSATION DUE TO INJURED EMPLOYEE
To the Industrial Accident Board of the State of Delaware
Sitting in and for
County
Claimant SS#
}
Claimant
Date of Birth
Insurance Carrier
vs.
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
PETITION TO DETERMINE COMPENSATION DUE TO INJURED EMPLOYEE
To the Industrial Accident Board of the State of Delaware
Sitting in and for
County
Claimant SS#
}
Claimant
Date of Birth
Insurance Carrier
vs.
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 #
rd
5. Name of Insurance Carrier / 3
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
Dated: _______ Day of _____________, 20____
I swear or affirm that the information contained in this statement
is true and correct to the best of my knowledge and recollection.
I understand and acknowledge that any falsehood contained in
this statement may expose me to civil or criminal liability.
______________________________________
Employee Signature
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