Wisconsin > Workers Comp
Compromise Review Application WKC-7-B - Wisconsin
| Compromise Review Application Form. This is a Wisconsin form and can be used in Workers Comp . |
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COMPROMISE REVIEW APPLICATION Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov The provision of your social security number is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. WC Claim Number Social Security Number Injury Date Applicant Attorney Mailing Address (if any) Employer Name Employer Mailing Address Employer Name (if more than one) Employer Mailing Address (if more than one) Briefly describe how injury occurred: Applicant Name Applicant Mailing Address Applicant Attorney Name (if any) Insurance Company Name Insurance Company Name Nature of Disability: (Indicate part of body injured and kind of disability as either strain or fracture) Date the order affirming the compromise was issued: _______________________________________________ List all reasons why the applicant feels compromise settlement was unjust: Where should hearing be scheduled? I will be ready for full hearing at any time after the following date: ___________ /___________ /___________ If not fully prepared for hearing, state reason here: Applicant Signature Date Signed If it is claimed that greater disability has resulted than was anticipated at the time of settlement, application should be accompanied by physician's report, stating the extent of disability claimed. WKC-7-B (R. 03/2009) American LegalNet, Inc. www.FormsWorkFlow.com
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