Petition For Review Of Findings And Order Of Administrative Law Judge
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Petition For Review Of Findings And Order Of Administrative Law Judge Form. This is a Wisconsin form and can be use in Workers Comp.
Loading PDF...
Tags: Petition For Review Of Findings And Order Of Administrative Law Judge, WKC 28, Wisconsin Workers Comp,
STATE OF WISCONSIN LABOR AND INDUSTRY REVIEW COMMISSION PETITION FOR REVIEW OF FINDINGS AND ORDER OF ADMINISTRATIVE LAW JUDGE (DWD) , Applicant vs. , Respondent , Insurance Carrier TO THE DEPARTMENT OF WORKFORCE DEVELOPMENT, WORKER'S COMPENSATI ON DIVISION, MADISON, WISCONSIN The undersigned petitions for a review of the law findings issued on (mo/day/year) The specific finding(s) which the petitioner claims are in error are as follows for the reasons stat ed: Petitioner Signature Date Signed Petitioner Street Address City, State, Zip Code NOTE: You must provide a copy of the petition to the opposing party or parties. SEE REVERSE SIDE FOR FILING IN STRUCTIONS. WKC - 28 (R. 0 7 /2018) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS A petition must be filed within 21 calendar days from the date which appears on the findings and decision or order of the Administrative Law Judge. For worker's compensation claims, the petition for review (appeal) may be filed online with the Labor and Industry Review Commission (Commission) at http://lirc.wisconsin.gov/wcappeal.htm (preferred method) or may be filed by mail, facsimile, or personal delivery. A petition filed by mail or personal delivery is deemed filed only when it is actually received by the Commission, the Worker's Compensation Division of the Department of Workforce Development, or by the Division of Hearings and Appeals - Office of Worker's Compensation Hearings (OWCH). A petition for review transmitted by facsimile is not deemed filed unless and until the petition is received and printed at the recipient facsimile machine of the Commission, the Worker's Compensation Divi sion, or OWCH. The petition may be filed at the office of the Labor and Industry Review Commission, 3319 West Beltline Highway, P. O. Box 8126, Madison WI 53708 (FAX: 608 - 267 - 4409); at the Worker's Compensation Division of the Department of Workforce Deve lopment, 201 East Washington Avenue, P.O. Box 7901, Madison WI 53707 (FAX: 608 - 267 - 0394); or at any of the following Office of Worker's Compensation Hearings ' locations : 4822 Madison Yards Way, Fifth Floor , P.O. Box 7922, Madison WI 5370 7 (FAX: 608 - 266 - 0018); 819 North Sixth Street, Milwaukee WI 53203 (FAX: 4 14 - 227 - 4012); or 54 Park Place, Suite 900, Appleton WI 54914 (FAX: 920 - 832 - 5355). American LegalNet, Inc. www.FormsWorkFlow.com
