State of Wisconsin Forms in Microsoft Word

WKC-3-E

Medical Treatment Statement — For listing charges from medical providers, or for medicine and supplies.

WKC-7-B

Compromise Review Application

WKC-12-E

Employer’s First Report of Injury or Disease — This is a Word file that is protected from modification and enabled for form fill (includes tabbed fields for form completion).

WKC-13-E

Supplementary Report on Accidents and Industrial Diseases — Supplemental report to be filed by the insurer or self-insured employer when payments are started, stopped, suspended or changed.& This version is protected from modification and enabled for form fill (includes tabbed fields for form completion).& This is a Word document.

WKC-13A-E

Wage Information — To be filed with the Department by the insurer or self-insured employer when wage used is less than the maximum compensation rate.& This version is protected from modification and enabled for form fill (includes tabbed fields for form completion).& This is a Word document.

WKC-16-E

Medical Report on Industrial Injuries — To be filed by the insurer or self-insured employer when temporary disability exceeds 3 weeks or permanent disability results.

WKC-16-A-E

Physician’s Report on Eye Injuries& Printable version& WKC-16-A& (R. 12/2009)

WKC-16-B

Practitioner’s Report on Accident or Industrial Disease in Lieu of Testimony& Printable version&&

WKC-17

Subpoena

WKC-19-E

Admission to Service and Answer to Application — To be filed by the respondent insurer or employer with the Department and the party filing application for hearing. Must be filed within 20 days after service of the application to the Department

WKC-28

Labor and Industry Review Commission Petition for Review of Findings and Order of Administrative Law Judge — To be used by a party to appeal administrative law judge’s order to the Labor and Industry Review Commission.

WKC-34

License Application

WKC-35

WC Hearing Appearance Permit Application

WKC-140

Supplemental Payments Reimbursement Request

WKC-170

Third Party Proceeds Agreement — To be filed by the insurance carrier with the Department for approval of distribution.

WKC-176

Compromise Agreement — To be filed by the parties with the Department for approval of compensation resolving a dispute.

WKC-177

Stipulation

WKC-6119

Social Security Reverse Offset Worksheet

WKC-6156

Social Security Information Request

WKC-6743

Vocational Expert Verified Report

WKC-7359-E

Instructions and worksheet to calculate Temporary Partial Disability Payments.

WKC-7602

Corporate Officer Option Notice

WKC-9380

Necessity of Treatment Dispute Resolution Request Form

WKC-9488-E

Consent Form for Release of Medical Information – This is an electronic format which may be completed on-line and printed for signatures.

WKC-9498

Reasonableness of Fee Dispute Resolution Request Form — This form should be used ONLY for fee disputes related to treatment provided on or after July 1, 1992.

WKC-10042

Private Vocational Rehabilitation Specialist Certification Application

WKC-10146

Notification of Services

WKC-10369

Private Vocational Rehabilitation Services Quarterly Report

WKC-12698

Self-Restriction Statement

WKC-15119-E

Joint Certificate of Readiness

WKC-15717-E

Certification of Readiness

WKC-15782-E

Termination Notice of Divided-Workforce

WKC-15783-E

Employer Notice of Divided-Workforce

WKC-15784-E

Employee Leasing Company Notification of a client covered under a master policy for small clients

WKC-15785-E

Wisconsin Proof of Coverage Notice under a master policy for small clients

WKC-16804-E&

Work Injury Supplemental Benefit Fund Barred Claim