Form K-Wc 97 - Request For Workers Compensation Records

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KANSAS DEPARTMENT OF LABOR
REQUEST FOR WORKERS
MAIL: Division of Workers Compensation
COMPENSATION RECORDS
401 SW Topeka Blvd., Suite 2
Topeka, KS 66603-3105
K-WC 97 (Rev. 3-14)
FAX: (785) 291-3430
(
)
Requestor name: _______________________________________________________ Phone: _______________________
(
)
Company or Entity: _____________________________________________________ Fax: __________________________
Address: ____________________________________________________________________________________________
City, State, ZIP: ______________________________________________________________________________________
Worker’s name: ________________________________________________________ SSN: _________________________
Records sought:
Accident report summaries
Docket summaries
Actual filings
Electronic download (registered users only; if not yet registered, see form K-WC 96)
In order to acquire accident reports or medical records, the requestor must be in category I or II below. Specify which
categories pertain to you and provide the accompanying information:
I) Are you:
the employer of a worker seeking workers compensation benefits
an insurance carrier with coverage of a worker seeking workers compensation benefits
an insurance carrier’s attorney/representative for the employer
Date of accident: __________________________________________________________________________________
II) Are you:
an employer which has made a conditional offer of employment to the individual whose records are sought
an insurance carrier of an employer which has made an employment offer to the individual whose records
are sought
an insurance carrier’s attorney/representative for the employer
Type of job conditionally offered to the individual: _________________________________________________________
The following release must be signed by the worker to whom the offer of employment was made:
I hereby verify that I have been offered employment by the individual or entity requesting my records from the Kansas Division of Workers
Compensation and give the division permission to release the records specified to the individual or entity making the request.
Signature of worker: __________________________________________________ Date: _______________________________________
I certify that all information provided by me is true and correct to the best of my knowledge. I understand that providing false or misleading
information may be a fraudulent or abusive practice under the Workers Compensation Act and may subject me to prosecution.
Signature of requestor: ________________________________________________ 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

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