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Fill and Sign the Compromise and Review Application for Workers Compensation Wisconsin Form

Fill and Sign the Compromise and Review Application for Workers Compensation Wisconsin Form

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Open the document and fill out all its fields.
Apply your legally-binding eSignature.
Save and invite other recipients to sign it.

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                                                                                                 Date the Order Affirming the compromise was issued:                               / /Compromise Review Application Department of Workforce Development Worker's Compensation Division 201 E. Washington Avenue, Rm. 161P.O. Box 7901Madison, WI 53707-7901Telephone: (608) 266-1340 Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(l)(m)). WC Claim Number Applicant Name Social Security Number Applicant Mailing Address Injury Date Applicant Attorney Name (if any) Applicant Attorney Mailing Address (if any) Employer Name Insurance Company Name Employer Mailing Address Employer Name (if more than one) Insurance Company Name Employer Mailing Address (if more than one) Briefly describe how injury occurred: Nature of disability: (Indicate part of body injured and kind of disability as either strain or fracture) List all reasons why the applicant feels compromise settlement was unjust: Where should hearing be scheduled? I will be ready for full hearing at any time after the following date: If not fully prepared for hearing, state reason here: Applicant Signature Date Signed If it is claimed that greater disability has resulted than was anticipated at the time of settlement, application should be accompanied by physician's report, stating the extent of disability claimed. WKC-7-B (R. 1/98)

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