ADMISSION TO SERVICE AND ANSWER TO APPLICATION You are the RESPONDENT in this matter. Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. WC Claim Number Employee Name Employee Social Security Number Employer Name Date of Alleged Injury Employer Mailing Address Insurance Company Name Insurance Company Mailing Address Respondent Attorney Name Department of Workforce Development Worker’s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov Respondent Attorney Mailing Address The enclosed hearing application must be answered within 20 days by mailing a copy of the answer to the Worker’s Compensation Division and to applicant’s attorney or applicant if unrepresented. Provide such responses as are now known and amend your responses later as necessary. The worker’s compensation insurer has a duty to defend and submit an answer on behalf of the employer except that the employer must defend and submit its own answer as to the following claims: (I) 15% increased compensation for safety violation, Wis. Stat. 102.57; (II) refusal to rehire, Wis. Stat. 102.35 (3); (III) penalty for late payment against employer, Wis. Stat. 102.22; (IV) penalty for illegal employment of minor, Wis. Stat. 102.60; and (V) bad faith against employer, Wis. Stat. 102.18 (1) (bp). Failure by the employer or insurer to file a timely answer may result in liability by default order. In answer to the application, using reverse side if additional space is necessary, the respondent states as follows: 1. The accident or occupational exposure occurred as alleged Admit Deny 2. The relationship of employer and employee existed Admit Deny 3. The parties were subject to the worker’s compensation act Admit Deny 4. At the time of alleged injury, the employee was performing service growing out of and incidental to employment Admit Deny 5. The accident or disease causing injury arose out of the alleged employment Admit Deny 6. Notice of injury was given to employer within 30 days/2 years of alleged injury Admit Deny 7. Applicant was temporarily disabled for the period claimed Admit Deny Admit Deny Admit Deny 10. The alleged employer was insured or self-insured under the Worker’s Compensation Act Admit Deny 11. Do you contend that additional parties must be joined for a complete resolution of applicant’s claim? If “yes,” attach expert opinions supporting joinder and explain who should be joined and why. Admit Deny If denied, state disability admitted: 8. Applicant is permanently disabled to the extent claimed If denied, state disability admitted: 9. The rate of wage claimed is correct If denied, state wage admitted: and attach a fully updated WKC-13-A 12. Describe any matters in dispute not already noted above and state all reasons for denying liability not already noted above. Insurance Carriers & Self-Insured Employers must attach an up-to-date WKC-13 and, if wage is disputed, an up-to-date WKC-13-A. Respondent Signature: Printed Name: Representing: Date Signed: Phone Number: ( Title: Insurance carrier and the insured interests of employer Insurance Carrier ) - Employer WKC-19-E (R. 08/2012) American LegalNet, Inc. www.FormsWorkFlow.com