Follow the steps to effectively complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editable format.
2. Begin by entering your WC claim number in the designated field. This number is essential for processing your application.
3. Fill in your full name as the applicant in the Applicant Name section. Ensure that it matches your official identification.
4. Provide your voluntary social security number in the corresponding field. Remember that not providing it may delay processing.
5. Enter your mailing address accurately in the Applicant Mailing Address section.
6. Specify the date of your injury. This information is crucial for your claim.
7. If you have legal representation, include your attorney's name and address in the respective fields. If not, you may leave them blank.
8. Next, provide the employer's name and insurance company name. If applicable, fill in details for additional employers.
9. In the brief description section, clearly outline how your injury occurred. Be concise but informative.
10. Indicate the nature of your disability by stating the affected body part and the type of disability (strain or fracture).
11. Record the date when the order affirming the compromise was issued. This is important for processing your application.
12. List the reasons why you believe the compromise settlement was unjust. Provide detailed explanations to strengthen your application.
13. Indicate where you would like the hearing to be scheduled. Provide a clear location.
14. State the earliest date you will be ready for a full hearing. This helps in scheduling your case.
15. If you are not fully prepared for a hearing, provide a brief explanation of why.
16. Sign the application in the designated space and enter the date signed, confirming the accuracy of the information.
17. After completing all sections, review the form for accuracy. You can save changes, download, print, or share the form as needed.

Encourage your peers to complete their applications online!