Fill and Sign the Wisconsin Workers Compensation Form 497431478

M FYes No Husband Wife Child Yes No Yes No If Yes, On What Date? Yes No If Yes, By Whom? Yes No Yes No Yes No                                                                                                                                                                                                   Temporary Total Disability (day, month and year)                         Temporary Partial Disability Permanent Total Disability Permanent Partial Disability                         Medical Expenses Denied Other:                               Yes                               Issues       GL35 GL33 GL33A GL35A GL70 GL39 GL48 GL34 GL31 Length      Date      ( ) ( ) ( ) ( ) HEARING APPLICATION Please read instructions on top sheet. Department of Workforce Development Worker's Compensation Division P.O. Box 7901, Madison, WI 53707-7901 (608) 266-1340 Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. Deaf, hearing or speech impaired callers may reach us through WI TRS. 1. Employee's Name, Address, City, State, Zip 2. Employer's Name, Address, City, State, Zip (At Time of Injury) 3. WC Insurance Carrier, Address, City, State, Zip 1A. Employee's Social Security No. 1 B. Employee's Telephone No. (include area code) 2A. Employer's Telephone No. (include area code) 3A. Insurance Carrier Telephone No. (area code) 1C. Date of Birth (mo/day/yr) Sex 2B. Nature of Employer's Business 3B. Date of Injury (mo/day/yr) 1D. Employee's Attorney (if any) Name & Full Address 2C. Employee's Occupation When Injured 3C. Last Date Employee Worked Before Disability 2D. Employee's Gross Weekly Wage When Injured 3D. Date Notice of Injury Given to Employer (mo/dav/vr)- ANSWER QUESTIONS 4 TO 4C IF CLAIM IS MADE FOR DEATH BENEFIT 4. Name of Deceased and Date of Death 4B. Are You a Dependent of the Deceased? 1E. Attorney's Telephone No. (include area code) 4A. Relation to Deceased 4C. Did You Live With the Deceased? 5. Describe the nature of the disability, parts of the body affected, how the injury or death occurred. 6. Check the boxes below for which compensation is being sought and specify detail, if known: 6A. From TO From TO 6B. 6C. 6D. From TO Starting Date- % 6E. 6F. Transportation Costs (mileage, etc.) 6G. $ $ 7. Names and Addresses of Medical Practitioners Who Treated Applicant: 8. Has Employee Returned to Work? Did Employee Return to Same Employer? 9. Was Medical Expense Paid? 1 0. Are You Currently Receiving Worker's Compensation? 11. Have Sickness and Accident Benefits/Income Continuation Been Paid for 11A. If Yes, Indicate By Whom and the Amounts. Lost Wages or Medical Expenses? 12. I Will Be Ready For A Formal Hearing On or After The Date Indicated 13. I Request the Hearing Be Scheduled at the Wisconsin City Shown Here: Here: 14. 15. FOR OFFICE USE ONLY: HR PT NR Date Signed Employee's Signature If represented, do you agree that an attorney's fee, fixed by the Department at no more than 20% of your recovery, may be paid directly from the compensation you recover? WKC-7 (R. 10/2000)