KANSAS DEPARTMENT OF LABOR www.dol.ks.gov PLAN AMENDMENT K-WC-R 93-3C (10-13) Amendment number: ___________________ Original plan start date: ___________________ Claimant: ________________________________________________ Social Security number: _____________________ Vendor: _______________________________________________________________ Vendor number: _____________ Counselor: _____________________________________________________________ QRP number: ______________ Estimated weekly earnings at plan completion: $ _____________________ Reason for plan amendment: Additional, deleted or extended services Begin date End date Claimant views (required): Claimant responsibilities: Counselor responsibilities: Claimant signature: ____________________________________________________________ Date: _______________ Counselor signature: ___________________________________________________________ Date: _______________ Insurance carrier or employer signature: ____________________________________________ Date: _______________ cc: DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000, ext. 2152 American LegalNet, Inc. www.FormsWorkFlow.com