CERTIFICATE OF READINESS FOR HEARING REQUEST TO SCHEDULE A HEARING The applicant's representative must file a Certificate of Readiness [COR] before the Office of WC Hearings (OWCH) will place the case in ready to be scheduled for hearing status. Explanation: The COR verifies that the case is ready for hearing and reduces the risk that a case scheduled for hearing will need to be postponed. The COR should also be used to encourage settlement discussions to resolve the case without the need for a hearing. General Instructions: Do not submit a COR until the applicant is certain that no other parties will be necessary. Do not submit the COR unless the WKC-16-B, vocational reports, or other essential medical reports are on file or are filed with the COR. The WKC-3 is not required to be filed with the COR. The OWCH will schedule hearings within 100 miles of the applicant's mailing address unless the applicant indicates a willingness to travel further, or has indicated a specific hearing location on the Hearing Application. Besides the dates of unavailability provided on this form, the attorneys should keep the OWCH calendar section notified of future dates of unavailability. Duty Disability claims require a denial letter from Employee Trust Funds (ETF). Please note the following general guidelines: Once scheduled, the OWCH will not postpone a hearing except for extraordinary circumstances. Gathering medical proof IS NOT an extraordinary circumstance. With the exception of reports filed in support of the COR, and unless waived by the parties, statutory deadlines for filing reports apply. If the status or nature of the claim changes after filing the COR, the applicant's representative must immediately notify the OWCH in order to prevent the scheduling of a hearing. If a scheduled case is postponed for this reason, the OWCH will require a new COR before scheduling another hearing. The parties should notify the OWCH in writing of address changes. American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF READINESS AND REQUEST TO SCHEDULE A HEARING Do not use this form to amend the Hearing Application. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. Employee Name Claim Number Date of Injury Employer Name WC Carrier or Self-Insured Employer Name Will employee travel more than 100 miles? Yes No ISSUES TO BE HEARD 226 MARK THE APPROPRIATE BOXES Average Weekly Wage $ Estimate of Medical Expenses $ Is the cause of injury (work relatedness) in dispute? Yes No Are you seeking an order on prospective medical treatment? Yes No Are you seeking TTD? Yes No If yes, list dates: Are you seeking TPD? Yes No If yes, list dates: Are you seeking PPD? Yes No If yes, list percentage: and body part: Are you seeking LOEC? Yes No If yes, list percentage: % Are you seeking Vocational Retraining? Yes No Other issues? Is an Interpreter needed? Yes No If yes, specify language: WC Carrier or Self-Insured Employer's Attorney Name Attach a list of all dates attorney is NOT available for hearings in the next 120 days Certification: By signing this Certificate of Readiness, I represent that I am ready for hearing. Employee's Attorney's Signature Date Signed The WC carrier or self-insured employer has 15 days to OBJECT in writing to this Certificate of Readiness setting out the specific reasons. WKC-15717-DHA (R. 05/2018) State of Wisconsin\DIVISION OF HEARINGS AND APPEALS Brian Hayes, Administrato r Office of Worker's Compensation Hearings P.O. Box 7922 Madison, WI 53707 Telephone: (608) 266-7709 FAX: (608) 266-0018 Email: DHAWCMail@wisconsin.gov American LegalNet, Inc. www.FormsWorkFlow.com