Kansas > Workers Compensation
Application For Hearing K-WC-E-1 - Kansas
| Application For Hearing Form. This is a Kansas form and can be used in Workers Compensation . |
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KANSASDEPARTMENTOFLABOR www.dol.ks.gov DO NOT WRITE IN THIS SPACE APPLICATION FOR HEARING K-WCE-1(Rev.6-12) Employee:_______________________________________________ First Middle Last Dateofbirth:______________________ Male Female Employer:________________________________________________ Street:___________________________________________________ City:__________________________State:______ZIP:__________ Insurancecarrier: __________________________________________ (Required) SocialSecuritynumber: ____________________________________ Street: __________________________________________________ City:________________________State:______ZIP: __________ _ Phone:__________________________________________________ Email:__________________________________________________ ACCIDENTAL INJURY OR OCCUPATIONAL DISEASE Date(s)ofaccident/disease(give beginning and ending dates if a series):________________________________________________________ _______________________________________________________________________________________________________________ Statespecificallytheexactcauseandsourceofaccident/disease:__________________________________________________________ _______________________________________________________________________________________________________________ Brieflystateextentofinjuriesordiseaseclaimed:________________________________________________________________________ Inwhatcountydidtheaccident/diseaseoccur?________________________Atornear(city)______________________(state) _______ Ifaccident/diseasedid nothappenwithinKansas,inwhichKansascountycouldhearingbemostconvenientlyheld?_________________ Mediationrequested? YES NO Applicantsignature:___________________________________________Date:___________________ DO NOT WRITE IN THIS SPACE Attorneysignature:_______________________________________ Printedname: __________________________________________ Street: ________________________________________________ City:__________________________State:______ZIP:__________ Email: ________________________________________________ Phone:________________________________________________ (for purposes of hearing notices) KansasSupremeCourtnumber:____________________________ Federal Privacy Act Disclosure Section 7(a)(2)(B) ThemandatoryrequirementthatSocialSecuritynumbersbeincludedonformsfiledwiththeDivisionofWorkersCompensationispermitted bySection7(a)(2)(B)oftheFederalPrivacyActof1974,sinceourregulationswhichrequireitsdisclosurewereinexistencebeforeJanuary1, 1975.ThenumberisusedasameansofidentifyingallthevariousrecordsintheDivisionofWorkersCompensationpertainingtoanindividual. TheuseofSocialSecuritynumbersismadenecessarybecauseofthelargenumberofapplicantswhohavesimilarnamesandbirthdates, andwhoseidentitiescanonlybedistinguishedbytheSocialSecuritynumber. DIVISIONOFWORKERSCOMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone:(785)296-4000·Fax:(785)296-8580 American LegalNet, Inc. www.FormsWorkFlow.com
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