Get Petition To Determine Compensation Due - Division Of Industrial Affairs

Filling out the Petition To Determine Compensation Due is an important step in addressing compensation disputes. This guide will walk you through each section of the form to ensure that users, regardless of their legal experience, can successfully complete it online.

Follow the steps to accurately complete the petition online.

1. Press the ‘Get Form’ button to access the Petition To Determine Compensation Due form and open it in your preferred editor.
2. Begin with the claimant information. Provide the name, social security number, and date of birth of the claimant in the designated fields.
3. Next, fill in the insurance carrier's name and the case file number, ensuring all details are accurate.
4. Indicate the employer's details, including the name, contact name, and address.
5. Complete the section regarding the statement of facts. Describe the nature of the dispute regarding the compensation due.
6. Add details about the accident or illness, including the date, location, occupation of the employee at the time of the incident, and a description of the accident.
7. List the body parts affected and indicate whether the employee received any medical care.
8. Document the notice of injury to the employer, as well as the names and addresses of all employers the claimant has had in the last five years.
9. State the weekly wage of the employee at the time of injury.
10. Provide information about all treating doctors and hospitals involved in the claimant's treatment, including their names and addresses.
11. Describe the extent of the injury’s impact on the employee’s ability to work and their recovery status.
12. After filling out all required sections, ensure to sign the petition and date it.
13. Finally, review all the information provided for accuracy before saving your changes, downloading, printing, or sharing the completed form.

Complete your Petition To Determine Compensation Due online to ensure your rights are protected.