Free (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

Full Name of Deceased Employee____________________________________ Date of Birth___________________________________________ Social Security Number__________________________________ Address at Time of Death_________________________________
(city)________________________ (state)_______ (Zip)_________

Name of Employer______________________________________ Address (street)_________________________________________
(city)________________________ (state)_______ (Zip)_________

Insurance Carrier_______________________________________

SURVIVING SPOUSE, DEPENDENT OR HEIR APPLICATION FOR HEARING
Date of death ________________, ______

ACCIDENTAL INJURY OR OCCUPATIONAL DISEASE Date of accident or disease ________________, ______ Hour _____ ___ M.

How did accident occur? _______________________________________________________________________________ ____________________________________________________________________________________________________ In what county did accident occur? _____________________ at or near (city)________________________ (state)________ If accident did not happen within state of Kansas, county where hearing could be most conveniently held? _______________________ SURVIVING SPOUSE, DEPENDENTS OR HEIRS Name Address E-mail Address Age Relationship ____________________ ____________________________________________ ____________________ ____________________________________________ ____________________ ____________________________________________ ____________________ ____________________________________________ ________________________________________
Applicant's Printed Name

______________ _____ ___________ ______________ _____ ___________ ______________ _____ ___________ ______________ _____ ___________ ______________
Date

________________________________________
Applicant's Signature

DO NOT WRITE IN THIS SPACE

Attorney for Applicant___________________________________ Attorney's Printed Name_________________________________ Address (street)________________________________________
(city)_______________________ (state)_______ (Zip)_________

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-2 (Rev. 5-07)