Free K-WC E 1 - Application For Hearing (Rev. 05-07) - Kansas

800 S.W. Jackson Street, Suite 600, Topeka, KS 66612-1227 phone ­ 785-296-3441 · fax ­ 785-296-8580 web site ­ www.dol.ks.gov

Division of Workers Compensation Kansas D epartment of Labor

DO NOT WRITE IN THIS SPACE

Employee's Name: ________________________________________________________
(first) (middle) (last)

APPLICATION FOR HEARING
Employer:________________________________________________ Street:___________________________________________________ City:_________________________ State: ______ Zip:__________

Date of Birth: ______________________

Male

Female

Social Security Number: ____________________________________ Address: (Street)____________________________________________
(City) _________________________ (State) ______ (Zip) __________

Phone Number: ___________________________________________ Employee E-mail Address: __________________________________

Insurance Carrier:___________________________________________
(Required)

ACCIDENTAL INJURY OR OCCUPATIONAL DISEASE
Date of accident/disease (give beginning and ending dates if a series):___________________________________________________________ _______________________________________________________________________________________________________________ State specifically the exact cause and source of accident/disease:___________________________________________________________ _______________________________________________________________________________________________________________ Briefly state extent of injuries or disease claimed:________________________________________________________________________ In what county did the accident or disease occur? ________________________ At or near which city?_____________________________ If accident/disease did not happen within Kansas, in which Kansas county could hearing be most conveniently held? _________________ Mediation Requested? YES NO Date Signed:_____________________________

Applicant's Signature:____________________________________________________

DO NOT WRITE IN THIS SPACE

Attorney's Signature: _______________________________________ Attorney's Printed Name: ____________________________________ Address:_________________________________________________ ________________________________________________________ Telephone Number: (_________) _____________________________ E-mail Address: ___________________________________________
(for purposes of hearing notices)

Kansas Supreme Court Number: ______________________________ Federal Privacy Act Disclosure Section 7(a)(2)(B)
The mandatory requirement that social security numbers be included on forms filed with the Division of Workers Compensation is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which require its disclosure were in existence before January 1, 1975. The number is used as a means of identifying all the various records in the Division of Workers Compensation pertaining to an individual. The use of social security numbers is made necessary because of the large number of applicants who have similar names and birth dates, and whose identities can only be distinguished by the social security number. K-WC E-1 (Rev. 5-07)