Form For Electronic Filing of Petition for Review

To file a petition for review electronically, complete this form and follow the filing instructions below. Fields marked with an asterisk (*) are mandatory and must be completed.

I hereby petition for review by the Labor and Industry Review Commission of the ALJ's decision in the following Worker's Compensation matter:

(Instructions are shown to the right of each form field)

Petition Information:

* Required Field Claim Number(s):

Enter the claim number(s) as shown on the first page of the ALJ's Decision.

* Required Field Date of Decision:

Enter the date of the Administrative Law Judge's decision.

Statement Regarding Timeliness of Petition:

If this petition is not being filed within 21 days of the date of the Administrative Law Judge's decision, provide a specific and complete explanation why here.

Applicant:

Enter the name of the applicant as shown on the first page of the ALJ's Decision.

Employer:

Enter the name of the employer as shown on the first page of the ALJ's Decision.

Insurer:

Enter the name of the insurer as shown on the first page of the ALJ's Decision.

Statement of Reasons for Petition:

Please enter a statement of the reasons this petition is being filed.

*Required Field Do you want a Briefing Schedule?

Yes, I want a briefing schedule
No, I don't want a briefing schedule

*Required Field Do you request a copy of the synopsis?

Yes, I want a copy of the synopsis
No, I don't want a copy of the synopsis

Information about the person filing this petition:

* Required Field Your Name:

The person filing this petition should enter his or her name here and indicate if he or she is the applicant, the employer, or the insurer, or an attorney or representative of one of those parties.

I am the:

Applicant
Applicant's Atty/Representative

Employer
Employer's Atty/Representative

Insurer
Insurer's Atty/Representative

* Required Field Address:

The person filing this petition should enter his or her mailing address here.

* Required Field City:

The person filing this petition should enter his or her city here.

* Required Field State:

The person filing this petition should enter his or her state here.

* Required Field Zip Code:

The person filing this petition should enter his or her zip code here.

Telephone:

(Optional)

Email:

A confirmation message will be sent to any e-mail address entered here. (Optional)

Filing instructions:

Before you proceed, check the information entered above to ensure that it is complete and correct.
After you click the "File Petition" button below, you should see a confirmation page. Your petition is not filed until you see this confirmation page. If you do NOT see the confirmation page, or you are for any other reason unable to complete the electronic filing process, you must use another means to file your petition.

You should print and keep a copy of the confirmation page. If there is a question about whether or when you filed a petition, you may be asked to produce a copy of that page.
If you have questions about how to complete or use this form, you may contact the commission by telephone during normal business hours (7:45 AM to 4:30 PM), at 608-266-9850.
To file your petition, click on the "FILE PETITION" button below -

Wisconsin Labor and Industry Review Commission

Form For Electronic Filing of Petition for Commission Review (Worker's Compensation)

Filing instructions: