Safety & Loss Prevention

AUTHORIZATION TO RELEASE EMPLOYMENT RECORDS

I, _______________________, do hereby authorize to disclose to University of Wisconsin-___________________ all information relating to my employment records, specifically to include but not exclusive to a description of my duties; physical requirements necessary to perform the job; a position description; the date of hire; shift hours worked; earnings paid on a weekly basis commencing ____________; nature and extent of any worker’s compensation injuries reported; name, address and phone number of the worker’s compensation insurance carrier covering said injuries. The purpose or need for this disclosure is to evaluate compensability for insurance purposes of alleged injuries under the Wisconsin Worker’s Compensation Act.

I, also, understand that this consent is revocable except to the extent that action has been taken in reliance there on and that this consent will remain in force for one year in order to effectuate the purpose for which it is given.

A photostatic copy of this authorization is to be given the same force and effect as the original.

Dated this _________ day of ______________________________, at Madison, Wisconsin.