Wisconsin Labor and Industry Review Commission

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


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:

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

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

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.

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

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

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

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

*Required Field Do you want a Briefing Schedule?



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



*Required Field Will you be ordering a transcript?



Information about the person filing this petition:

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:







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

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

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

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

(Optional)

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


Filing instructions:



LIR-15357-E (R.12/2013)