Worker's Compensation PreHearing and Hearing Appearance Permit Application
Personal information you provide may be used for secondary purposes, (Privacy law, s. 15.04(1)(m).
Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: [email protected]
Applicant Name
Applicant Address
City
State
Zip Code
Applicant Telephone Number ( )
I apply for permission to appear at a worker's compensation hearing for: ______________________________________
In the matter of: Employee Name WC Claim Number
Employee Social Security Number
Injury Date
vs. Employer Insurance Company
I certify that I am 18 years of age or older and do not have an arrest or conviction record.
I certify that I have obtained permission to appear on ____________________ prior occasions. I have attached a statement of my background, training and experience (if any) in Worker's Compensation matters.
Applicant Signature _____________________________________________________Date Signed__________________
Permission to appear granted. Administrative Law Judge Signature ________________________________________Date Signed__________________ ALJ Comments:
WKC-35 (R. 07/2001)