Certification of Readiness for Hearing and Request to Schedule a Hearing or Settlement Conference Certification of Readiness by the applicant’s representative is required before scheduling will begin. Failing to submit the Certification of Readiness may ultimately result in dismissal of the Application for Hearing. Explanation: • Submission of a Certification of Readiness by the applicant’s representative is verification that the matter is ready for hearing or settlement conference. It is intended to allow for scheduling without the risk that the applicant will request an adjournment. • The Certification of Readiness also is intended to encourage settlement discussions, resulting in earlier case resolution without the necessity of a scheduled hearing. General Instructions: • Do not submit a Certification of Readiness if the applicant believes that further impleader or joinder of parties is a possibility. • Do not submit a Certification of Readiness unless the WKC-16B or alternative medical report was previously submitted or included with the Certification of Readiness. • The Worker’s Compensation Division will try to schedule the hearing at a location no more than 100 miles from the address of the employee or the employer unless the employee indicates a willingness to travel further. • In addition to the dates of unavailability for the attorney provided on this form, the attorney should continue to notify the department’s calendar section of any future dates of unavailability. Please note the following general guidelines for scheduling hearings: • No postponements will be granted except under extraordinary circumstances. Difficulty in gathering medical proof IS NOT an extraordinary circumstance. • Issues in addition to those listed on the Certification of Readiness form may be heard at the scheduled event if the notice and filing requirements in Wis. Stat. ch. 102 and Wis. Admin. Code ch. 80 are met or by stipulation of the parties. • Unless waived by the parties, statutory filing deadlines apply. The applicant’s representative is required to file all medical and vocational proof prior to submitting the Certification of Readiness. • If the status or nature of the claim changes after the Certification of Readiness is filed and the employee is no longer ready to proceed, the applicant’s representative must immediately notify the department in order to prevent scheduling of a hearing or settlement conference. American LegalNet, Inc. www.FormsWorkflow.com Department of Workforce Development Division of Worker’s Compensation 201 E. Washington Avenue P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 e-mail: DWDDWC@dwd.wisconsin.gov Certification of Readiness and Request to Schedule a Hearing or Settlement Conference The provision of your social security number 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]. Employee Name Social Security Number Claim Number Date(s) of Injury: Employee Street Address City State Yes Is Date of Injury in Dispute? Zip Code Phone Number Employer Name City State Zip Code Phone Number Employer Street Address City State Zip Code Phone Number WC Carrier Name: WC Carrier Contact Name: Address: Phone Number: Indicate the event you wish to schedule: Formal Hearing No Can Employee Travel more than Yes No 100 miles? Settlement Conference ISSUES TO BE HEARD – PLEASE MARK THE APPROPRIATE BOXES BELOW Average Weekly Wage (Claimed/Admitted) Yes $ Medical Causation? No Yes Yes Order for Future Medical Care? Temporary Total Disability? Yes If yes, indicate the dates at issue below: No Permanent Partial Disability? Yes No Medical Expense? No Yes No Estimate of Medical Bills: $ If yes, explain the nature of the treatment at issue: Yes Temporary Partial Disability If yes, indicate the dates at issue below: No No Yes No Loss of Earning Capacity? Percentage Claimed and Body Part: Percentage Claimed: Percentage Conceded and Body Part: Percentage Conceded: Disfigurement? Yes No Death Benefits? Yes No Safety Violation? Yes No Delay Penalties (Specify in Detail the Delayed Payment[s] and Who Caused the Delay – Insurer or Employer) Other Issues to be Heard (Specify in Detail) Interpreter Needed? Yes Employee’s Attorney Name No Street Address Insurer’s Attorney Name Employer’s Attorney Name If yes, language needed: City State Zip Code Phone Number Street Address City State Zip Code Phone Number Street Address City State Zip Code Phone Number List all dates for which the attorney or representative will NOT be available in the next 90 Days Certification: I, the undersigned Applicant’s representative, attest that I am fully ready and prepared to proceed to a formal hearing or settlement conference as indicated for the issues identified above. I further attest that I have contacted the insurer’s representative and have shared all necessary information and documentation to resolve the dispute. The insurer’s representative has either denied this claim in full or has had at least 90 days notice of the claim in order to investigate it. I believe that this matter cannot be resolved without a formal hearing or settlement conference. Applicant’s Attorney Signature WKC-15717 (R. 01/2009) Date Signed American LegalNet, Inc. www.FormsWorkflow.com