Kansas > Workers Compensation
Application For Preliminary Hearing K-WC-E-3 - Kansas
| Application For Preliminary Hearing Form. This is a Kansas form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
KANSAS DEPARTMENT OF LABOR www.dol.ks.gov DO NOT WRITE IN THIS SPACE APPLICATION FOR PRELIMINARY HEARING K-WC E-3 (Rev. 6-12) Docket number (if known): ___________________________________ Phone: __________________________________________________ Employee: _______________________________________________ First Middle Last Email: ___________________________________________________ Employer: ________________________________________________ List date of accident if a docket number has not been assigned: ____________________________________________________________ (the date should match the date on the Application for Hearing, Form E-1) 1. This form must be accompanied by a completed Application for Hearing, Form E-1, unless Form E-1 was previously filed for this accident. 2. This form must be accompanied by a copy of the notice of intent required by K.S.A. 44-534a(a). 3. This form must be accompanied by the applicant's certification that the notice of intent was served on the adverse party and the requested benefit change was denied or not answered within seven days after service. 4. This form must be accompanied by copies of medical reports or other evidence which the party intends to produce as exhibits supporting the benefit change. (If no medical reports are available, that fact should be noted in the applicant's certification.) 5. If the party is represented by an attorney, this form shall be signed by at least one attorney of record as required by K.S.A. 44-536a(a). 6. Are you interested in going through the Workers Compensation mediation process? Applicant signature: ______________________________________________________ YES NO Date: ______________________________ Address:________________________________________________________________________________________________________ Attorney signature: ______________________________________ Printed name: __________________________________________ Street: ________________________________________________ City: __________________________ State: ______ ZIP: __________ Email: ________________________________________________ (for purposes of hearing notices) DO NOT WRITE IN THIS SPACE Phone: ________________________________________________ Kansas Supreme Court number: ___________________________ Federal Privacy Act Disclosure Section 7(a)(2)(B) The mandatory requirement that Social Security numbers be included on forms filed with the Division of Workers Compensation is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which require its disclosure were in existence before January 1, 1975. The number is used as a means of identifying all the various records in the Division of Workers Compensation pertaining to an individual. The use of Social Security numbers is made necessary because of the large number of applicants who have similar names and birth dates, and whose identities can only be distinguished by the Social Security number. DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone: (785) 296-4000 · Fax: (785) 296-8580 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
