APPENDIX B – REVISED RULES OF APPELLATE PROCEDURE
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Complete Case Title: _______________________________________________________________
Petitioner: ________________________________Respondent: ______________________________
Counsel: _________________________________ Counsel: ________________________________
Claim No.: _______________________________ Board of Review No.: ______________________
Date of Injury/Last Exposure: ________________ Date Claim Filed: _________________________
Date and Ruling of the Office of Judges: ________________________________________________
Date and Ruling of the Board of Review: _______________________________________________
Issue and Relief requested on Appeal: __________________________________________________
CLAIMANT INFORMATION
Claimant's Name: __________________________________________________________________
Nature of Injury: ___________________________________________________________________
Age: _________ Is the Claimant still working? Yes No. If yes, where: _______________
Occupation: ___________________________________________ No. of Years: ________________
Was the claim found to be compensable? Yes No If yes, order date: ____________________
ADDITIONAL INFORMATION FOR PTD REQUESTS
Education (highest): _______________________ Old Fund or New Fund (please circle one)
Date of Last Employment: ___________________________________________________________
Total amount of prior PPD awards: _____________________ (add dates of orders on separate page)
Finding of the PTD Review Board: ____________________________________________________
List all compensable conditions under this claim number: ___________________________________
(Attach a separate sheet if necessary)
Are there any related petitions currently pending or previously considered by the Supreme Court?
Yes No
(If yes, cite the case name, docket number and the manner in which it is related on a separate sheet.)
Are there any related petitions currently pending below? Yes No
(If yes, cite the case name, tribunal and the manner in which it is related on a separate sheet.)
If an appealing party is a corporation an extra sheet must list the names of parent corporations and the name
of any public company that owns ten percent or more of the corporation's stock. If this section is not
applicable, please so indicate below.
The corporation who is a party to this appeal does not have a parent corporation and no publicly held
company owns ten percent or more of the corporation's stock.
Do you know of any reason why one or more of the Supreme Court Justices should be disqualified from
this case? Yes No
If so, set forth the basis on an extra sheet. Providing the information required in this section does not
relieve a party from the obligation to file a motion for disqualification in accordance with Rule 33.
Fred Flintstone v. Barney Rubble
