Free WKC-7-b.PDF - Wisconsin

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.state.wi.us/wc/ e-mail: [email protected]

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. 07/2001)