Case Information Sheet

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Vs





WC #-###-###-##
Case Information Sheet
hearing location

2. CASE STATUS Check and complete, as appropriate:

set for hearing.




3. Discovery 




5. ISSUES REMAINING FOR DETERMINATION Check all issues that remain:





6. List the lay witnesses you intend to call in your case-in-chief: 












7. List the expert witnesses you intend to call in your case-in-chief: 













(in minutes)
Signature











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Certificate of Mailing

I hereby certify that I mailed or delivered the original Case Information Sheet (CIS) to all parties at the addresses shown below (A claimant must provide a copy to the employer and the insurer, or their attorney):

Claimant/Respondent or their Representative









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Employer or their Representative









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Other









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