PJC General Negligence 2024

W ORKERS ’ C OMPENSATION —E XTENT - OF -I NJURY D ISPUTES

PJC 21.1

PJC 21.1 Extent of Injury—Question PJC 21.1A Extent of Injury—Question—When Claimant Appeals QUESTION ______ Does Paul Payne ’s compensable injury extend to and include the following conditions: [Insert applicable injury or diagnosis 1, 2, and 3 below.] Answer “Yes” or “No.” [ Injury or diagnosis 1 ]? Answer: _______________ [ Injury or diagnosis 2 ]? Answer: _______________ [ Injury or diagnosis 3 ]? Answer: _______________ PJC 21.1B Extent of Injury—Question—When Carrier Appeals QUESTION ______ Does Paul Payne ’s compensable injury not extend to and include the follow ing conditions: [Insert applicable injury or diagnosis 1, 2, and 3 below.]

Answer “Yes” or “No.” [ Injury or diagnosis 1 ]? Answer: _______________ [ Injury or diagnosis 2 ]? Answer: _______________ [ Injury or diagnosis 3 ]? Answer: _______________

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