Free WC Address - Wisconsin

INSTRUCTIONS FOR COMPLETION OF JOINT CERTIFICATION OF READINESS
1. Certification of readiness by the parties is not mandatory but is encouraged. 2. Any party may initiate the certification, but all parties must join in one certification. 3. Certification will facilitate, but will not guarantee, an earlier hearing date. 4. The Worker's Compensation Division will attempt to schedule the hearing at a location no more than 100 miles from the address of the employee or the employer. 5. Only matters that will be ready for hearing on short notice (30 days) should be submitted for consideration for a short-notice hearing. 6. No certification should be submitted if any party believes that further impleader or joinder of parties is a possibility. 7. No postponements will be granted except under extraordinary circumstances. Difficulty in gathering medical proof IS NOT an extraordinary circumstance. 8. If the Worker's Compensation Division approves the joint certification, a hearing may be scheduled on relatively short notice. The Worker's Compensation Division will notify the parties if the request is not approved. 9. Only the issues listed on the joint certification form will be heard at the scheduled hearing. 10. Unless waived by the parties, statutory filing deadlines apply. The parties are encouraged to file and exchange medical and vocational proof with the Joint Certification. 11. In addition to the dates of unavailability for the attorneys provided on this form, the attorneys should continue to notify the Calendar Section of any future dates of unavailability.

PLEASE NOTE:
The submission of a Joint Certification by the parties is a representation that the matter is ready for hearing on relatively short notice. This will afford the Calendar Section a number of claims that may be scheduled without the risk that a party might request an adjournment. The Joint Certification will provide the parties input into the scheduling of hearings. Those attorneys and parties that cooperate in the process of preparing a file for hearing will be afforded some priority in scheduling, thus achieving earlier resolution of their matters. The process of submitting a Joint Certification is expected to encourage settlement discussions, resulting in earlier case resolution.

Department of Workforce Development Division of Worker's Compensation 201 E. Washington Avenue P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 e-mail: [email protected] Employee Name Employee Street Address Employer Name Street Address WC Carrier Name and Address

Joint Certification of Readiness
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), Wisconsin Statutes]. Social Security Number City Claim Number State Date(s) of Injury: Is Date of Injury in Dispute? Yes Zip Code Phone Number Phone Number No

City

State

Zip Code

WC Carrier Contact Name and Phone Number

Can Employee Travel more than 100 miles? Yes No

ISSUES TO BE HEARD ­ PLEASE MARK THE APPROPRIATE BOXES BELOW
Average Weekly Wage (Claimed/Admitted) $ Order for Future Medical Care? Yes No Temporary Total Disability? Yes No Yes No Medical Causation? Yes No Medical Expense Yes No (If Yes, Attach WKC-3)

Nature of the Treatment at Issue Dates Temporary Partial Disability? Yes No Yes No Dates

Permanent Partial Disability? Percentage Claimed and Body Part Percentage Conceded and Body Part

Loss of Earning Capacity? Percentage Claimed Percentage Conceded

Disfigurement?

Yes

No

Death Benefits?

Yes

No

Safety Violation?

Yes

No

Delay Penalties (Specify in Detail the Delayed Payment[s] and Who Caused the Delay ­ Insurer or Employer)

Other Issues to be Heard (Specify in Detail)

Number of Witnesses for Employee Employee's Attorney Name

Number of Witnesses for Respondent Street Address City

Times Needed for Hearing 2 Hours 2 1/2 Hours State Zip Code

3 Hours

1/2 Day

Phone Number

Insurer's Attorney Name

Street Address

City

State

Zip Code

Phone Number

Employer's Attorney Name

Street Address

City

State

Zip Code

Phone Number

List All Dates for Which the Attorneys, Parties and/or Any Necessary Witness Will Not be Available in the Next 90 Days.

Attorney Signature and Date

Attorney Signature and Date

Attorney Signature and Date

WKC-15119 (R. 01/2009)