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Get WI WKC-9380 2012

Ne: (608) 264-6819 Fax: (608) 267-0394 http://dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov Direct all inquiries to: Medical Cost Dispute Unit and mail to the address above or telephone (608) 264-6819. INSTRUCTIONS: Complete Section 1 or Section 2 and all sections (3, 4 & 5) on the reverse side. You are the RESPONDENT in this matter. Provision of the Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you.

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