LHWCA Prehearing Statement Form

BEFORE THE UNITED STATES DEPARTMENT OF LABOR
                                     OFFICE OF ADMINISTRATIVE LAW JUDGES



Case Caption and No.

PREHEARING STATEMENT of:                      Claimant

                   Director, OWCP             Respondent


In accordance with 29 C.F.R. § 18.80, each party must complete and deliver to the other parties and the presiding judge a signed
prehearing statement no later than the date specified in the Notice of Hearing and Prehearing Order. For cases arising under the
Longshore and Harbor Workers' Compensation Act and its extensions, including the Defense Base Act, a party using this form
will be deemed to have satisfied the requirements of Section 18.80.


1. Briefly summarize, below or on attached sheet, the facts or circumstances you contend gave rise to this claim, and describe
   the nature of the claimed injury or disease.




2. State your contentions as to the place of injury                                                                                 ;


  its date                        ; the date disability commenced                          ; the date Claimant became

aware disability was work related                              ;      and the date employer had notice of injury                .

3. This claim is for:       compensation;         medical benefits;          penalties (under §                            );

                        other                                                                                              .


4. Your position is that:

    (a) The LHWCA applies to this claim?                                            Yes           No
    (b) At the time of the alleged injury, an employer-employee                     Yes           No
        relationship existed between Claimant and Employer?
    (c) Claimant has suffered injury or disease?                                    Yes           No
    (d) The alleged injury or disease arose out of and in the                       Yes           No
        course of Claimant's employment?

    (e) The claim was           timely noticed;     untimely filed?        timely filed;    untimely noticed;
    (f) Claimant is/was entitled to:     compensation?                              Yes           No
                                         medical benefits?                          Yes           No
    (g) Employer/Carrier is currently providing:      compensation?                 Yes           No
                                                      medical benefits?             Yes           No

    (h) Claimant has reached maximum medical improvement?                           No            Yes   on                          .
(i) Claimant has outstanding medical bills?          No               Yes

                                           to:                                                 $
                                                                                               $
                                                                                               $
5. Are nature and extent of disability disputed?          Yes               No
6. Is Claimant now working?                               No                Yes
                                                                in his/her usual employment started on                            ;
                                                                in alternative employment started on                              .
7. Your position is that Claimant was able to do:
            no work.          alternative work;           his/her regular pre-injury work without loss of earnings;
8. Your position is that the alleged injury or disease is:                  unscheduled; OR

           a scheduled injury which caused a                     % loss/loss of use of                                      .
9. Your position is that the alleged injury or disease caused disability which was/is:

         temporary total from                                            to
         temporary partial from                                          to
         permanent partial from                                          to
         permanent total from                                            to
10. Your position is that Claimant's average weekly wage when injured was                      $
    under § 10 subsection                                       , and that his/her retained weekly earning capacity is:   zero;

    OR         $                                        based on:           his/her current earnings;
                                                                            labor market survey(s);
                                                                            other facts.
11. Is Special Fund relief sought?        No              Yes
               If Yes, is the Director:                   conceding entitlement;
                                                          asserting absolute bar;
                                                          denying entitlement on grounds of:
                                                                no pre-existing disability;
                                                                disability not manifest to employer;
                                                               contribution requirement not met?

12. Set forth below or on separate page(s) other contentions, issues or ultimate facts which you will
    present at trial (e.g. last responsible employer; § 33(g); collateral estoppel; credits; etc.), and
    succinctly brief any novel legal questions.




13. State below or on separate page(s) the stipulated facts that require no proof (a sample
    stipulation form can be found at www.oalj.dol.gov/FORMS.HTM).
14. To the extent not previously provided on this Prehearing Statement form, state below or on
    separate page(s) the facts disputed by the parties.




15. Set forth below or on separate page(s) a list of witnesses you expect to call.




16. Set forth below or on separate page(s) a list of the joint exhibits.




17. Set forth below or on separate page(s) a list of the party's exhibits.




18. Estimated time required for you to present your case-in-chief:                        day(s) or                 hours
19. State below or on separate page(s) any additional information that may aid the parties' preparation for the hearing or the
disposition of the proceeding, such as the need for specialized equipment at the hearing.




DATE:                             /s/:


                                                              Representative for

                       Address:




                       Telephone
                       Number
                       Fax Number

                       E-mail Address


Rev 10/15
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