Free wkc-28.PDF - Wisconsin

STATE OF WISCONSIN LABOR AND INDUSTRY REVIEW COMMISSION PETITION FOR REVIEW OF FINDINGS AND ORDER OF ADMINISTRATIVE LAW JUDGE
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_____________________________________________________________, Applicant vs. _____________________________________________________________, Respondent _____________________________________________________________, Insurance Carrier TO THE DEPARTMENT OF WORKFORCE DEVELOPMENT, MADISON, WISCONSIN The undersigned petitions for a review of the law judge's findings issued on (mo/day/year)

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The specific finding(s) which the petitioner claims are in error are as follows for the reasons stated:

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Petitioner Signature Petitioner Street Address

Date Signed City, State, Zip Code

NOTE CAREFULLY: Petition must be received by the Department of Workforce Development within twenty-one (21) days from the date a copy of the findings or order of the law judge was mailed to the last known address of the parties at interest. The petition may be filed at the Worker's Compensation Division, 201 E. Washington Ave., P.O. Box 7901, Madison, WI 53707; or the Worker's Compensation Division, Associated Bank Building, 1500 North Casaloma Drive, th Suite 310, Appleton, WI 54915; or the Worker's Compensation Division, 819 N. 6 St., Milwaukee, WI 53203; or the office of the Labor and Industry Review Commission, 3319 West Beltline Highway, P.O. Box 8126, Madison, WI 53708
WKC-28 (R. 07/2001)