Free WKC-6156.PDF - Wisconsin

SOCIAL SECURITY INFORMATION REQUEST
The provision of your social security number is mandatory under Wisconsin Statutes and will be used to identify the claimant. Failure to provide it may result in penalties or delayed payment of benefits. Personal information you provide may be used for secondary purposes [(Privacy Law, s. 15.04(1)(m)]. See Reverse Side for Instructions

Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Imaging Server Fax: (608) 260-2503 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: [email protected]

1. WC Claim Number 3. Social Security Number 5. Injury Date

2. Employee Name 4. Employee Mailing Address (number, street, city, state, zip code)

Social Security Release Authority - To be completed by employee I authorize the Social Security Administration to release the information requested below to:
6. Insurance Company Representative or Self-Insured Employer Name 7. Mailing Address (number, street, city, state, zip code)

I understand that the information requested is for computing the amount of worker's compensation payments for which I would be entitled. The information below is not to be disclosed to others or to be used for other purposes without my additional consent. This authorization shall remain in effect for one year from the date below or until revoked by me in writing if earlier.
8. Signature (do not print) 9. Date Signed 10. Social Security Number (only if different from above)

Office Use Only Social Security Disability Benefit Information 11. Status of Disability Claim Approved Denied Pending No Claim Filed

12. 80% of Monthly Average Current Earnings (ACE) 13. Disability MBA for W/E at Initial Entitlement 14. Month and Year of Entitlement

$__________________________________________ $__________________________________________ __________________________________________

15. Month and Year of Last Disability Check if Terminated
16. SSA Representative Signature 17. Date Signed

__________________________________________
18. Telephone Number 19. Office Location

WKC-6156 (R. 02/2002)

SSA INSTRUCTIONS
Insurance Company or Self Insured Employer 1. 2. 3. 4. 5. 6. 7. · Enter WC claim number Enter employee's name Enter employee's social security number Enter employee's address Enter injury date Enter your name Enter your mailing address Send this form to the employee

Employee 8. Provide your signature, do not print 9. Enter date of your signature 10. Enter your social security number only if it is different from the number in "3." · Important Notice: Return this form to the address in "7." within 30 days. If you do not sign this form, your insurance carrier or employer can reduce your benefits by 75%. When you sign, any benefits that were withheld will be paid to you.

Insurance Company or Self Insured Employer · Once you receive this form from the employee, send the signed form to the SSA district office that handles this employee.

Social Security Administration · See TN 11 2-83 D100203.050 If any of the information below is not available, forward this form to Baltimore. The insurance carrier needs all this information, except Line 15, to compute a reverse offset. If the claim is currently being reviewed but payments were made in the past, please follow the instructions for 11 through 18: 11. 12. 13. 14. 15. 16. 17. 18. Enter status of the disability claim Enter 80% of ACE Enter MBA Enter month and year of entitlement Enter month and year of last disability check (only if benefits are ending) Have Social Security Administration representative's signature Enter date of Social Security Administration representative's signature Enter telephone number of Social Security Administration representative for possible questions from insurance carrier 19. Enter city · Send this completed form to the address in "7."

Insurance Company or Self Insured Employer · Fill out a Social Security Reverse Offset Worksheet. If you find that you can take an offset, send copies of this form and the Worksheet to: Worker's Compensation Division P.O. Box 7901 Madison, WI 53707 · The employee and Social Security Administration representative must sign this form or Reverse Offset will not be computed. Computerized forms from the Social Security Administration will not be accepted.