KANSAS DEPARTMENT OF LABOR www.dol.ks.gov WORKER'S REQUEST FOR WORKERS COMPENSATION RECORDS K-WC 98 (Rev. 3-14) MAIL: Division of Workers Compensation 401 SW Topeka Blvd., Suite 2 Topeka, KS 66603-3105 FAX: (785) 291-3430 This form is NOT to be used by employers to access workers compensation records. First name: ___________________________________________ MI: ________ Last name: _________________________________ Social Security number: _________________________________________ Street address or P.O. Box number: ______________________________________________________________________________ City: ____________________________________________________ State: _________________ ZIP: ________________________ ) ) Phone: ( ________________________________________________ Fax: ( _________________________________________________ Date(s) of accident(s) (mm/dd/yyyy): ______________________________________________________________________________ Specify the records you are requesting: Accident report summaries Actual filings Electronic download (registered users only; if not yet registered, see form K-WC 96) I am requesting that a copy of my records be sent to my legal representative: First name: _____________________________________ MI: _______ Last name: ____________________________________ Street address or P.O. Box number: __________________________________________________________________________ City: ______________________________________________________ State: ________________ ZIP: ___________________ I am requesting that a copy of my records be sent to me. Docket summaries I hereby verify that I am requesting accident report summaries, docket summaries or actual filings involving an accident or prior claim in which I either sought workers compensation or suffered an injury. I hereby give the Division of Workers Compensation permission to send my records to the person or persons specified above. Signature of worker: _______________________________________________________ Date: __________________________ Federal Privacy Act Disclosure Section 7(a)(2)(B) The mandatory requirement that Social Security numbers 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. DIVISION OF WORKERS COMPENSATION - RESEARCH UNIT 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone: (785) 296-4000, (800) 332-0353 · Fax: (785) 291-3430 American LegalNet, Inc. www.FormsWorkFlow.com