800S.W.JacksonStreet,Suite600,Topeka,KS66612-1227 phone785-296-3441·fax785-296-8580 websitewww.dol.ks.gov
Division of Workers Compensation Kansas D epartment of Labor
DO NOT WRITE IN THIS SPACE
Docket Number (if known): ______________________________________ Phone Number: ______________________________________________ Employee: __________________________________________________ Employee E-mail Address:______________________________________ Employer: ___________________________________________________
APPLICATION FOR PRELIMINARY HEARING
List date of accident if a docket number has not been assigned: _________________________________________________
(the date should match the date on the Application for Hearing, Form E-1)
1. ThisformmustbeaccompaniedbyacompletedApplicationforHearing,FormE-1,unlessFormE-1previouslyfiledforthisaccident. 2. This form must be accompanied by a copy of the notice of intent required by K.S.A. 44-534a(a). 3. Thisformmustbeaccompaniedbytheapplicant'scertificationthatthenoticeofintentwasservedontheadversepartyandtherequested benefitchangewasdeniedornotansweredwithinsevendaysafterservice. 4. Thisformmustbeaccompaniedbycopiesofmedicalreportsorotherevidencewhichthepartyintendstoproduceasexhibitssupporting thebenefitchange.(If no medical reports are available that fact should be noted in the applicant's certification.) 5. If the party is represented by an attorney, this form shall be signed by at least one attorney of record as required by K.S.A. 44-536a(a). 6. Are you interested in going through the Workers Compensation Mediation Process? Yes No
Applicant's Signature:____________________________________________________________________ Address: ______________________________________________________________________________ Signed this _______ day of ______________________________, _________ DO NOT WRITE IN THIS SPACE
Attorney's Signature:___________________________________________ Attorney's Printed Name:_______________________________________ Address:____________________________________________________ ___________________________________________________________ E-mail Address:_______________________________________________
(for purposes of hearing notices)
Telephone Number: (_________)_________________________________ Kansas Supreme Court Number:_________________________________
ThemandatoryrequirementthatsocialsecuritynumbersbeincludedonformsfiledwiththeDivisionofWorkersCompensationispermittedbySection 7(a)(2)(B)oftheFederalPrivacyActof1974,sinceourregulationswhichrequireitsdisclosurewereinexistencebeforeJanuary1,1975.Thenumberis used as a means of identifying all the various records in the Division of Workers Compensation pertaining to an individual. Theuseofsocialsecuritynumbersismadenecessarybecauseofthelargenumberofapplicantswhohavesimilarnamesandbirthdates,andwhose identities can only be distinguished by the social security number. K-WC E-3 (Rev. 5-07)
Federal Privacy Act Disclosure Section 7(a)(2)(B)