Fill and Sign the Admission to Service for Workers Compensation Wisconsin Form

Insurance Company Name Insurance Company Mailing Address (Number, Street, City, State, Zip Code) Respondent Attorney Name Respondent Attorney Mailing Address (Number, Street, City, State, Zip Code)                                                                     Admitted Admitted Admitted Admitted Admitted Admitted Admitted Denied Denied Denied Denied Denied Denied Denied If denied, state disability admitted:       Admitted Denied If denied, state disability admitted:       Admitted Denied If denied, state wage admitted:       Admitted Denied             Employer Insurance Co ( ) ADMISSION TO SERVICE AND ANSWER TO APPLICATION Department of Workforce Development Worker's Compensation Division 201 E. Washington Avenue, Rm. 161 You are the RESPONDENT in this matter. P.O. Box 7901Madison, WI 53707-7901Telephone: (608) 266-1340 Complete all blanks. Type or print legibly. Personal information you provide rnay be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. WC Claim Number Employee Name Employee Social Security Number Employer Name Date of Alleged Injury Employer Mailing Address (Number, Street, City, State, Zip Code) Enclosed is a copy of a hearing application filed with this office. The applicant charges that compensation or medical expense due for an alleged injury has not been properly paid. This application for worker's compensation benefits must be answered by you within 20 days. One copy of the answer should be mailed to the Worker's Compensation Division and one copy to the applicant or his/her attorney. Provide such responses as are now known and amend your responses later as necessary. If you concede that a portion of the claimed benefits is due and accrued, you should promptly make payment of those conceded amounts. You do not withhold payment because an application has been filed. If you accept liability for payment of compensation to the applicant, you should immediately pay that compensation which is due. This will save you and the applicant the expense It is the duty of the worker's compensation insurer to file the answer on behalf of the employer. The only exceptions are applications for 15% increased compensation due to the failure on the part of the employer to furnish a safe place and methods of employment or for wages lost due to unreasonable failure to rehire following a compensable injury. These must be answered by the emr)lover.of a hearing. Failure by the employer or insurer to file a timely answer may result in liability pursuant to a default order. In answer to the application, the respondent states: 1. The accident or occupational exposure alleged in the application actually occurred on or about the time claimed 2. The relationship of employer and employee existed 3. The parties were subject to the worker's compensation act 4. At the time of alleged injury, the employee was performing service growing out of and incidental to employment 5. The accident or disease causing injury arose out of the alleged employment 6. Notice of injury was given to employer within 30 days/2 years of alleged injury 7. Applicant was temporarily disabled for the period claimed S. Applicant is permanently disabled to the extent claimed 9. The rate of wage claimed is correct 10. The alleged employer was insured under the worker's compensation act 11. State exactly what matters are in dispute and your reason for denying liability. Use reverse side, if necessary. (if any statements are found to be incorrect, you may file an amended answer.) BE CERTAIN TO PROVIDE THE INFORMATION REQUESTED BELOW: Amount of compensation paid to date or currentWKC-13 showing all payment Respondent Signature Date Signed Representing Phone- WKC-19 (R. 10/2000)