Kansas > Workers Compensation
Surviving Spouse Or Dependent Application For Hearing K-WC E-2 - Kansas
| Surviving Spouse Or Dependent Application For Hearing 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 SURVIVING SPOUSE, DEPENDENT OR HEIR APPLICATION FOR HEARING K-WC E-2 (Rev. 6-12) Deceased employee: __________________________________________________ First Middle Last Date of birth: ________________________________________________ Employer: ___________________________________________ Social Security number: _______________________________________ Address: ____________________________________________ Address at time of death: ______________________________________ City: _____________________ State: ________ ZIP: _________ City: ________________________ State: _________ ZIP: ____________ Insurance carrier: _____________________________________ (Required) ACCIDENTAL INJURY OR OCCUPATIONAL DISEASE Date of accident/disease _________________________ Time: ______:_____ c A.M. c P.M. Date of death: ___________________ How did accident occur? ___________________________________________________________________________________________ ________________________________________________________________________________________________________________ In what county did accident occur? ____________________________ at or near (city)____________________________ (state)________ If accident/disease did not happen within Kansas, in which Kansas county could hearing be most conveniently held? _________________ SURVIVING SPOUSE, DEPENDENTS OR HEIRS Name Address Email Age Relationship ______________________ _______________________________________________ ____________________ _____ _____________ ______________________ _______________________________________________ ____________________ _____ _____________ ______________________ _______________________________________________ ____________________ _____ _____________ ______________________ _______________________________________________ ____________________ _____ _____________ ________________________________________ Applicantprintedname ________________________________________ Signature ______________ Date DO NOT WRITE IN THIS SPACE Attorney signature: ____________________________________ Printed name: ________________________________________ Street: ______________________________________________ City: _______________________ State: ______ ZIP: _________ Email:_______________________________________________ Phone:______________________________________________ (forpurposesofhearingnotices) 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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