Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to

process and resolve your workers’ compensation dispute. The data will be used by department of labor and industry (department) staff who have

authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim

may be delayed or denied, or the form may be returned to you. The data will be made part of the department’s file for your claim and may be supplied

to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative

hearings; the workers’ compensation court of appeals; the departments of revenue and health; and the workers’ compensation reinsurance

association.