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Fill and Sign the Wkc 35 Wc Hearing Appearance This is an Application for Permission to Appear at a Workers Comensation Hearing Form

Fill and Sign the Wkc 35 Wc Hearing Appearance This is an Application for Permission to Appear at a Workers Comensation Hearing Form

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Open the document and fill out all its fields.
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*Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for seconda ry purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. Applicant Name Applicant Address City State Zip Code Applicant T elephone Number ( ) I apply for permission to appear at a worker’s compensation hearing for: In the matter of: Employee Name W C Claim Number Employee Social Security Number * Injury Date vs. Employer Insurance Company I certif y that I am 18 years of age or older and do not have an arrest or conviction record. I certify that I have obtained permission to appear on ____________________ prior occasions. I have attached a statement of my background, training and experience (if a ny) in W orker’s Compensation matters. Applic ant Signature Date Signed Permission to appear granted. Administrative Law Judge Signature Date Signed ALJ Comments: W KC -35 (R. 06 /20 17 ) Worker’s Compensation PreHearing and Hearing Appearance Permit Application Department of Workforce Development Worker’s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707 -7901 Telephone: (608) 266 -1340 Fax: (608) 267 -0394 http:// dwd.wisconsin .gov/ wc e-mail: DWDDWC@dwd. wisconsin.gov

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