Last updated: 11/30/2016
Request For Cross Examination {07-6174}
Start Your Free Trial $ 13.99What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
ALASKA DEPARTMENT OF LABOR Alaska Workers Compensation Board P.O. Box 25512 Juneau, Alaska 99802-5512 AWCB Case Number Request for Cross-Examination Instructions: This form is to be filed to request cross-examination of the author of any report listed on a Medical Summary or any nonmedical document. To be used when you file an Affidavit of Readiness for Hearing, an Affidavit of Opposition, or a Medical Summary or within 10 days after another party files a Medical Summary. 1. Employees Name (Last, First, Middle Initial) 4. Address City 7. Employer 9. Address City State Zip Code Telephone State Zip Code Telephone 8. Insurer/Adjusting Company 10. Address City State Zip Code Telephone 2. Insurer Claim No. 3. Date of Injury 5. Social Security Number 6. Date of Birth I REQUEST THE OPPORTUNITY TO CROSS-EXAMINE THE FOLLOWING WITNESSES FOR THE REASONS STATED: 11. Date of Medical Summary Prepared By a. 12. Medical Report Date Report Author 13. Reason Cross-Examination is Requested (Be Specific) b. c. d. e. 14. Nonmedical Document Date Document Description a. 15. Document Author 16. Reason Cross-Examination is Requested (Be Specific) b. 17. Name of Person Submitting Request (Print or Type) 19. Address 18. Signature City State Zip Code Telephone 20. PROOF OF SERVICE: I certify that on the date in #23 below I mailed/delivered a true and correct copy of this request to the following (request will be returned with no action if all parties are not served): a. o The employee in #1 above at the address in #4 b. o The employer in #7 above at the address in #9. c. o The insurer in #8 above at the address in #10. d. o Other (state name and address): NAME NAME 21. Name of Person Serving Request 22. Signature ADDRESS ADDRESS 23. Date Served Form 07-6174 (1/94) American LegalNet, Inc. www.FormsWorkFlow.com 74
Related forms
-
Affidavit Of Compensation Rate Less Than $154
Alaska/Workers Comp/ -
Affidavit Of Readiness For Hearing
Alaska/Workers Comp/ -
Application For Certificate Of Self Insurance
Alaska/Workers Comp/ -
Compensation Report
Alaska/Workers Comp/ -
Compromise And Release Agreement Summary
Alaska/Workers Comp/ -
Controversion Notice
Alaska/Workers Comp/ -
Death Benefits Report
Alaska/Workers Comp/ -
Employers Notice Of Insurance
Alaska/Workers Comp/ -
Notice Of Possible Claim Against The Second Injury Fund
Alaska/Workers Comp/ -
Petition To Join Second Injury Fund And Claim For Reimbursement
Alaska/Workers Comp/ -
Physicians Report
Alaska/Workers Comp/ -
Release Of Counseling Psych Psychiatric Or Alcohol Drug Substance Abuse Treatment Records Or Info
Alaska/Workers Comp/ -
Renewal Certificate Of Self Insurance
Alaska/Workers Comp/ -
Request For Conference
Alaska/Workers Comp/ -
Request For Cross Examination
Alaska/Workers Comp/ -
Subpoena
Alaska/Workers Comp/ -
Second Independent Medical Evaluation (SIME)
Alaska/Workers Comp/ -
Report Of Occupational Injury Or Illness
Alaska/Workers Comp/ -
Waiver Of Reemployment Benefits
Alaska/Workers Comp/ -
Employee Report Of Occupational Injury Or Illness To Employer
Alaska/Workers Comp/ -
Change Of Address
Alaska/Workers Comp/ -
Notice Of Appearance
Alaska/Workers Comp/ -
Notice Of Intent To Rely
Alaska/Workers Comp/ -
Public Records Request
Alaska/Workers Comp/ -
Request For Release Of Information
Alaska/Workers Comp/ -
Affidavit Verifying SIME Records Are Complete
Alaska/Workers Comp/ -
Claim For Workers Compensation Benefits
Alaska/Workers Comp/ -
Release of Medical Information
Alaska/6 Workers Comp/ -
Firefighters Lung And Heart Physical Examination And Cancer Screening
Alaska/6 Workers Comp/ -
Firefighters Medical History And Evaluation
Alaska/6 Workers Comp/ -
Fishermens Fund Claim Form
Alaska/6 Workers Comp/ -
Fishermens Fund Compelling Reasons Questionnaire (Form 07-6124}
Alaska/6 Workers Comp/ -
Fishermens Fund Physicians Report
Alaska/6 Workers Comp/ -
Application To Provide Reemployment Services As A Rehabilitation Specialist
Alaska/6 Workers Comp/ -
Reemployment Eligibility Evaluation Checklist
Alaska/6 Workers Comp/ -
Employer Notice Of 45 Consecutive Days Of Time Loss For Injuries
Alaska/6 Workers Comp/ -
Reemployment Employer Notice Of 90 Consecutive Days Of Time Loss For Injuries
Alaska/6 Workers Comp/ -
Offer Of Alternative Employment
Alaska/6 Workers Comp/ -
Reemployment Benefits Plan Checklist
Alaska/6 Workers Comp/ -
Reemployment Stipulation To Eligibility For Injuries
Alaska/6 Workers Comp/ -
Fishermens Fund Report Of Vessel Site Insurance
Alaska/6 Workers Comp/ -
Guide For Preparing Reemployment Benefits Eligibility Form
Alaska/6 Workers Comp/ -
Fishermans Fund Request For Release Of Information
Alaska/Workers Comp/ -
Crewman Agreement Regarding Medical Related Transportation Or Other Expenses
Alaska/Workers Comp/ -
Election To Either Receive Reemployment Benefits Or A Job Dislocation Benefit
Alaska/Workers Comp/ -
Medical Summary
Alaska/Workers Comp/ -
Petition
Alaska/Workers Comp/
Form Preview
Contact Us
Success: Your message was sent.
Thank you!