Free Wkc-35.PDF - Wisconsin

Worker's Compensation PreHearing and Hearing Appearance Permit Application

Personal information you provide may be used for secondary purposes, (Privacy law, s. 15.04(1)(m).

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]

Applicant Name

Applicant Address

City

State

Zip Code

Applicant Telephone Number ( )

I apply for permission to appear at a worker's compensation hearing for: ______________________________________

In the matter of: Employee Name WC Claim Number

Employee Social Security Number

Injury Date

vs. Employer Insurance Company

I certify that I am 18 years of age or older and do not have an arrest or conviction record.

I certify that I have obtained permission to appear on ____________________ prior occasions. I have attached a statement of my background, training and experience (if any) in Worker's Compensation matters.

Applicant Signature _____________________________________________________Date Signed__________________

Permission to appear granted. Administrative Law Judge Signature ________________________________________Date Signed__________________ ALJ Comments:

WKC-35 (R. 07/2001)