Free K-WC E 5 - Application For Review and Modification (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

Docket Number (required): _______________________________________ Phone Number: _______________________________________________ Employee: ___________________________________________________ Employee E-mail Address: ______________________________________ Employer: ___________________________________________________

APPLICATION FOR REVIEW AND MODIFICATION
(Date of Award or Order)

This is an application for review and modification of the decision entered on _______________________________________ 1. Set forth a reason listed in K.S.A. 44-528 for which modification is sought: ___________________________________________ ______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 2. 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). 3. Are you interested in going through the Workers Compensation Mediation Process? Yes No

Applicant's Signature: ___________________________________________________________________ Address: _____________________________________________________________________________ Signed this _______ day of ______________________________, 20____ 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:_________________________________ 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-5 (Rev. 5-07)