Fill and Sign the Advancement or Lump Sum Request for Workers Compensation Wisconsin Form

Married Separated Single Divorced Yes No                                                             If ''Yes'' Start Date:                   Your gross salary or wages $             Hours Per Week:                               under 18 years of age:       Child Support Obligation:       Savings:                                                                                                ( ) ( ) Wisconsin Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. 161 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266- 1340 ADVANCEMENT OR LUMP SUM REQUEST Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. WC Claim Number - office use only Employee NameToday's Date Social Security Number Employee Address (Number, Street, City, State and Zip Code) Injury Date Employee Telephone Number Date of Birth Marital Status: Are you currently employed? Employer Name Employer Phone Number Employer Address (Number, Street, City, State, Zip) pe r Present income of injured (all sources) Social Security Benefits If spouse employed, enter gross wages: $ pe r Number of dependents Property owned by injured (personal and real estate) Estimated Value Amount of money owed on property Give the amount and reason why advancement is requested. Be specific. Provide copies of bills that are in arrears. Certified as correct by: (signature of injured employee) Signatur e Date Signed Return completed form to: Worker's Compensation Division, P.O. Box 7901, Madison, Wl 53707-7901 WKC-136 (R. 7/96)