HEARING APPLICATION Please Read Ins tructions . Provision of your Social Security Number (SSN) is mandatory under Section 111 of Medicare, Medicaid and SCHIP Extension Act 2007 (42 U.S.C. s. 1395y (b) (7) & (8)) and will be used to identify the claimant . Failure to provide it may result in pe nalties and delayed payment of benefits. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. 1. Employee Name, Address, City, State, Zip 2.Employer Name, Address, City, State, Zip (At Time Of Injury) 3. WC Insurance Carrier, Address , City, State, Zip 3a. Insurance Carrier Telephone No. (Area Code) ( ) - 3b. Date o f Injury (Mo/Day/Yr) 1a. Employee Social Security No. 2a . Federal Employer Identification Number ( If Known ) 3c. Last Date Employee Worked Before Disability 1b. Employee Telephone No. (Include Area Code) ( ) - 2 b . Employer Telephone No. (Include Area Code) ( ) - 3d. Date Notice o f Injury Given t o Employer 1c. Date o f Birth (Mo/Day/Yr) S ex M F 2c . Nature o f Employer Business 4. Have You Ap p lied f or or a re You Receiving Social Security Benefits? Yes No 1d. Employee Attorney ( if a ny) Name & Full Address 2d . Employee Occupation When Injured 4 a . Have You Applied f or or a re You Covered Under Medicare? Yes No If Yes, Medicare Claim Number 2e . Employee Gross Weekly Wage When Injured Answer Questions 5 To 5 c If Claim Is Made For Death Benefit 1e. Is the Certification of Readiness i ncluded w ith t his Applicat ion? Yes No 5 . Name o f Deceased a nd Date o f Death 5 a . Are You a Dependent o f t he Deceased? Yes No 1 f . ( ) - 5 b t o Deceased Husband Wife Child Other 5 c . Did You Live w ith t he Deceased? Y es No 6 . How did the Injury or Death Occur? If PossibleSpecify if Single Event or Long-Term Exposure. 6a. Describe Parts of the Body Affected 7 . Check the Boxes Below for which Compensation is being Sought and Specify Detail, if known 7 a. Temporary Total Disability (Day, Month a nd Year) From To From To 7 b. Temporary Partial Disability From To 7 c. Transportation Costs (Mileage) 7 d. Permanent Partial Disability % o f Body Part 7 e. Permanent Total Disability Starting Date 7 f . Medical Expense Denied $ Has Treatment Ended? Yes No 7 g. Penalty 7 h. Other 8. Names of Medical Practitioners who Treated Applicant 9. Is t he Employee Working Now? Yes No 10 . Were Med ical Expenses Paid Yes No If Yes, By Whom? 11 Disability Benefits? Yes No 12 . Have Sickness a nd Acci dent Benefits / Income Continuation b een Paid f or Lost Wages ? Yes No 1 2 a . If Yes , Indicate b y w hom a nd t he Amounts 13 . I will be Ready for a Formal Hearing in Due Course Due Course b ut not b efore t his Date . 14 . I Request the Hearing be Scheduled at the Wisconsin City shown here 15 . Employee Si gnature Date Signed If Represented, do y ou a gree t hat a f ixed b y t he Department a t n o m ore t han 20% o f y our Recovery, m ay b e p aid d irectly from the Compensation y ou Recover? Yes No 16 . FOR OFFICE USE ONLY: HR PT NR Issues GL35 GL35A GL48 Length GL33 GL70 GL34 Date GL33A GL39 GL31 WKC-7 (R. 05/2018) Department of Workforce Development 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707 Telephone: (608) 266 - 1340 Litigated Fax: (608) 26 0 - 3053 http s :// dwd.wisconsin .gov /wc American LegalNet, Inc. www.FormsWorkFlow.com