Kansas > Workers Compensation
Application For Review Of Modification K-WC E-5 - Kansas
| Application For Review Of Modification Form. This is a Kansas form and can be used in Workers Compensation . |
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KANSAS DEPARTMENT OF LABOR www.dol.ks.gov DO NOT WRITE IN THIS SPACE APPLICATION FOR REVIEW AND MODIFICATION K-WC E-5 (Rev. 6-12) Docket number (required): ____________________________________ Phone: ___________________________________________________ Employee: ________________________________________________ First Middle Last Email: __________________________________________________ Employer: _________________________________________________ This is an application for review and modification of the decision entered on _________________________________________________ (Date of award or order) 1. Set forth a reason listed in K.S.A. 44-528 for which modification is sought: _____________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 2. 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). 3. Are you interested in going through the Workers Compensation mediation process? YES NO Applicant signature: ____________________________________________________________________ Date: _____________________ Address: _______________________________________________________________________________________________________ Attorney signature: ______________________________________ DO NOT WRITE IN THIS SPACE Printed name: __________________________________________ Street: _______________________________________________ City: __________________________ State: ______ ZIP: __________ Email: _______________________________________________ (for purposes of hearing notices) Phone: ________________________________________________ Kansas Supreme Court number:____________________________ 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. Federal Privacy Act Disclosure Section 7(a)(2)(B) 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
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