Case number (if known): Employee: First Middle LastPhone: Email: Employer: List date(s) of accident/repetitive trauma/occupational disease if a case number has not been assigned: (the date(s) should match the date(s) on the Application for Hearing, Form E-1)þ This form must be accompanied by a completed Application for Hearingrepetitive trauma/disease.2. þ This form must be accompanied by a copy of the notice of intent required by K.S.A. 44-534a(a). þ þ This form must be accompanied by copies of medical reports or other evidence which the party intends to produce as exhibits supporting 5. þAre you interested in going through the Workers Compensation mediation process? YES NO þ Applicant printed name þ Signature þ Date Address: Federal Privacy Act Disclosure Section 7(a)(2)(B) þ by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which require its disclosure were in existence before January 1, þ The use of Social Security numbers is made necessary because of the large number of applicants who have similar names and birth dates, and whose identities can only be distinguished by the Social Security number.DIVISION OF WORKERS COMPENSATION401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 225 Phone: (785) 296-4000 225 Fax: (785) 296-8580 DO NOT WRITE IN THIS SPACE DO NOT WRITE IN THIS SPACE Date StampDO NOT USE THIS FORM IF YOU ARE AN ATTORNEY OR HAVE AN ATTORNEYBy completing this form and submitting it to the Division, you certify that you are not represented by an attorney for the matter referenced herein. American LegalNet, Inc. www.Forms