Free K-WC 98 - Worker's Request For Workers Compensation Records (Rev. 02-09) - Kansas


File Size: 176.7 kB
Pages: 1
Date: February 11, 2009
File Format: PDF
State: Kansas
Category: Workers Compensation
Word Count: 324 Words, 2,009 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dol.ks.gov/WC/html/kwc98(Rev-02-09).pdf

Download K-WC 98 - Worker's Request For Workers Compensation Records (Rev. 02-09) ( 176.7 kB)


Preview K-WC 98 - Worker's Request For Workers Compensation Records (Rev. 02-09)
KANSAS DEPARTMENT OF LABOR www.dol.ks.gov

Page 1 of 1

Worker's Request for Workers Compensation Records
K-WC 98 (Rev. 2-2009)

This form is NOT to be used by employers to access Workers Compensation records.
Federal Privacy Act Disclosure Section 7(a)(2)(B) The mandatory requirement that social security number be included in 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.

First Name: Social Security Number: Street Address OR P.O. Box Number: City: Phone (include area code): Date of Accident(s): Specify the records you are requesting: ­

MI

Last Name:

State:

Zip +4 Code: Fax: ­ Docket summaries

Accident report summaries

Actual filings only if requested (2-3 days for processing)

A

I am requesting that a copy of my records be sent to: MI Last Name:

1. First Name: Street Address OR P.O. Box Number: City:

State:

Zip +4 Code:

2. First Name: Street Address OR P.O. Box Number: City:

MI

Last Name:

State:

Zip +4 Code:

B

I hereby verify that I am requesting accident report summaries, docket summaries or actual filings involving an accident or prior claim in which I either sought workers compensation or suffered an injury. I hereby give the Division of Workers Compensation permission to send my records to the person or persons specified above.

Signature of Worker:

Date:
DIVISION OF WORKERS COMPENSATION 800 SW Jackson Street, Suite 600, Topeka, KS 66612-1227 Phone: 785-296-2996 · Fax: 785-291-3430 · Toll Free: 1-800-332-0353 · E-mail: [email protected]