KANSAS DEPARTMENT OF LABOR Written Claim for Workers Compensation In order to protect your rights for possible future workers compensation benefits, a written claim must be filed with your employer within 200 days after one of the following: • The date of accident, • The last compensation paid or • The last approved medical treatment. An accident report filed with the Division of Workers Compensation IS NOT a written claim. To file a written claim with your employer: In-person: Complete the bottom half of this form and give to your employer. Have employer complete and sign the top half as acknowledgement of receipt of your written claim – keep for your records. By mail: Complete bottom half of form and mail to your employer by certified mail, return receipt requested. Employee’s Receipt ATTENTION: This receipt is for employee’s records. Do not send to the Division of Workers Compensation. I hereby acknowledge receipt of written claim: Employer’s Signature________________________________________________ Date Received:___________________________ Employee’s name:___________________________________________________________________________________________ Date of alleged accident:______________________________________________________________________________________ (For Employee’s Records) (For Employer) Written Claim for Workers Compensation Date: (month/day/year)________________________________ To (employer):_____________________________________________________________________________________________________ Street:_____________________________________________ City:____________________ State: _______ Zip:_________________ You are herewith informed that I claim compensation in accordance with the Workers Compensation laws of Kansas by reason of an accident which arose out of and in the course of my employment with you on or about (date: month/day/year)________________________________ Signature (worker making claim):____________________________________________ Social Security No.:____________________________ Street:_____________________________________________ City:______________________ State: _______ Zip:_________________ EMPLOYER INSTRUCTION: Please forward this claim to your workers compensation insurance carrier or to your self-insurance claim processing office. Federal Privacy Act Disclosure Section 7(a)(2)(B) The mandatory requirement that social security number be included in forms filed with the Division of Workers Compensation is permitted 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, 1975. The number is used as a means of identifying all the various records in the Division of Workers Compensation pertaining to an individual. 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. K-WC 15 (Rev. 2-06) American LegalNet, Inc. www.USCourtForms.com