____________________________________
____________________________________
____________________________________
____________________________________
 

_____________________________________
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 _________________, 2006.

                                                                                                _______________________________
                                                                                                     Petitioner
 

* If additional space is needed, please attach sheet to this petition for hearing.