CCR1984222RESOLUTION 1/222-84
AUTHORIZING EXECUTION OF "ADMISSION TO SERVICE"
(As Amended)
(Workmen's Compensation - Police Officer)
WHEREAS, Officer Kenny Brian Putt was employed by the City of
Muskego Police Department on September 30, 1983, and
WHEREAS, Officer Putt was disabled as a result of an injury
sustained while on duty on the date aforementioned, and,
WHEREAS, the City of Muskego has received an application for
hearing wherein Officer Putt has claimed benefits due and owing
while on duty, and,
under Section 40.65 Wisconsin Statutes for disability sustained
WHEREAS, the City of Muskego acknowledges that Officer Putt has
suffered a permanent and disabling injury as a result of the
aforementioned incident and is, therefore,, entitled to said
benefits under Section 40.65 Wisconsin Statutes,
NOW, THEREFORE, BE IT RESOLVED, that the Common Council
authorized and directs the Mayor of the City of Muskego to
execute the Admission to Service and Answer to Application" of
Officer Kenny Brian Putt, in the form of the copy annexed hereto
and incorporated herein by reference forthwith, thereafter
Industry, Labor and Human Relations, Worker's Compensation
forwarding same to the State of Wisconsin, Department of
Division forthwith.
BE IT FURTHER RESOLVED that the Common Council authorizes and
directs the Mayor of the City of Muskego to sign the Stipulation
in the form of the copy attached hereto, said Stipulation to be
State of Wisconsin.
filed with the Department of Industry, Labor and Human Relations,
II
DATED THIS 23rd DAY OF October , 1984.
FINANCE COMMITTEE
Ald. Edwin Du&-e r. - L"/I 3cue_Q,
Ald.PQitche1 Penovich
ATTEST :
/&d>U
Ald. Rdlph Tomczyk
RESOLUTION #222-84 / /
AUTHORIZING EXECUTION OF "ADMISSION TO SERVICE"
(Workmen's Compensation - Police Offiker)
/'
WHEREAS, Officer Kenny Brian Putt was the City of
Muskego Police Department on September 30, 1983, and
WHEREAS, Officer Putt was disabled as a repult of an injury
sustained while on duty on the date aforementioned, and,
WHEREAS, the City of Muskego has receiyed an application for
hearing wherein Officer Putt has claiyed benefits due and owing
under Section 40.65 Wisconsin Statutes for disability sustained
while on duty, and,
/
/
WHEREAS, the City of Putt has
suffered a permanent and
aforementioned incident entitled to said
benefits under Section
NOW, THEREFORE, BE IT RESOLVED, that the Common Council
authorized and directs the Fyor of the City of Muskego to
Officer Kenny Brian Putt, /in the form of the copy annexed hereto
execute the "Admission to Qervice and Answer to Application" of
and incorporated herein br reference forthwith, thereafter
forwarding same to of Wisconsin, Department of
Industry, Labor and Relations, Worker's Compensation
Division forthwith.
DATED THIS DAY OF , 1984.
FINANCE COMMITTEE
ATTEST :
/ I Charlotte Stewart, Clerk /
A1ahel PehovLch
I I, Ald. Ralph Tomczyk u/
'ADM~SSION TO SERVICE THE STATE OF WISCONSIN
AND ANWER TO APPLICATION Drpanmenl of Industry.
WORKER'SCOMPENSATION DlWSlON
Ln~r and Humh kclarions
P.O. Box 7901 Madtron 53707 a 'ate 111 blanks. Typa or print legibly.
ANT NAME APPLICANT SOCIAL SECURITV NUMBER
Kenny Brian Putt 311-64-8396
City of Muskego Police DeFt.
S8150 Racine Avenue
Muskego, WI 53150
EMPLOYER NAME AND ADDRESS INSURER NAME AND ADDRESS
N/A
DATE OF ALLEGED INJURY
9-30-83
RESPONDENT ATTORNEV NAME AND ADDRESS
Arenz, Molter, Macy 6 Riff
916 Clinton Street
Waukesha, WI 53187
P.O. Box 1348
I I I
IN ANSWER TO THE APPLICATION. THE RESPONDENT STATES:
1.
2
7.
4.
6.
6.
7.
8.
9.
10.
11.
THE ACCIDENT OR OCCUPATIONAL EXPOSURE ALLEGED IN THE APPLICATION ACTUALLY OCCURRED ON
OR ABOUT THE TIME CLAIMED.
THE RELATIONSHIP OF EMPLOYER AND EMPLOYE EXlSTED.
THE PARTIES WERE SUBJECT TOTHE WORKER'SCOMPEHSATION ACT
AT THE TIME OF ALLEGED INJURV THE EMPLOYE WAS PERFORMING SERVICE GROWING OUT OF AND
INCIDENTAL TO EMPLOYMENT,
THE ACCIDENT OR DISEASE CAUSING INJURY AROSE OUI OF THE ALLEGED EMPLOb"ENT
NOTICE OF lNJURY WAS GIVEN EMPLOVER WITHIN 30 DAVS OF ALLEGED INJURY.
THE ALLEGED EMPLOYER WAS INSURED UNDER THE WORKER'S COUPENSATION ACT,
AMOUNT OF COMPENSATION PAID TO DATE NAME ANDSIGNATURE OF RESPONDENT DATED
None S40.65 Wis. Stats.