Stipulations with Request for Award
Coversheet data, SSN and venue location
Applicant name and address
If there is an Employer then there has to be a Claims Administrator
Injured worker name and address. Permanent or temporary disability information.
Information to compute the attorney fee
Limited to 256 characters
Contains the SSN, Date of Injury and Venu information
All the disability payment information
Optional, however, is the TemporaryDisabilityStartDate is entered then the EndDate and Amount are required
Optional, however if the Start date is entered then the endDate, rate and amount are required.
The permanent disability amount, start and end dates
Limited to 12 characters
Radio buttons indicating the need for medical treatment to cure or relieve effects
Limited to 189 characters
Limited to 440 characters
Interpreter name and license number
Other stipulation information