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Wisconsin Form Center -

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Form

Description

wkc12e.pdf Employer First Report of Injury or Disease - Print copy. Use link above for electronic filing.
wkc13.pdf Supplementary Report on Accidents and Industrial Diseases. Print copy. Use link above for electronic filing.
wkc3.pdf Medical Treatment Statement
wkc7.pdf Hearing Application -- To be filed by a party with the Department requesting resolution of a dispute. Please call (608) 266-1340 or email request to wcadmin@dwd.wisconsin.gov to order the form.
wkc7b.pdf Compromise Review Application
wkc13a.pdf Wage Information Supplement
wkc16.pdf Medical Report on Industrial Injury
wkc16a.pdf Physicians Report on Eye Injuries
wkc16b.pdf Practitioners Report on Accident or Industrial Disease in Lieu of Testimony
wkc17.pdf Subpoena
wkc19dha.pdf DHA Admission to Service and Answer to Application
wkc28.pdf Petition for Review of Findings and Order of Administrative Law Judge
wkc34.pdf License Application
wkc35.pdf WC Hearing Appearance Permit Application
wkc140.pdf Supplemental Payments Reimbursement Request
wkc170.pdf Third Party Proceeds Agreement
wkc176.pdf Compromise Agreement
wkc177.pdf Stipulation
wkc6119.pdf Social Security Reverse Offset Worksheet
wkc6156.pdf Social Security Information Request
wkc6743.pdf Vocational Expert Report
wkc7359-1e.pdf Worksheet to Calculate Temporary Partial Disability Payments.
wkc7602.pdf Corporate Officer Option Notice
wkc9351.pdf Health Service Fee Database Certification Application
wkc9380.pdf Necessity of Treatment Dispute Resolution Request Form
wkc9488.pdf Voluntary and Informed Consent for Disclosure of Health Care Information
wkc9488s.pdf Voluntary and Informed Consent for Disclosure of Health Care Information (Spanish)
wkc9498.pdf Reasonableness of Fee Dispute Resolution Request Form
wkc10042.pdf Private Vocational Rehabilitation Specialist Certification Application
wkc10146.pdf Notification of Services by Private Rehabilitation Specialist
wkc10369.pdf Private Vocational Rehabilitation Services Quarterly Report
wkc12698.pdf Self-Restriction Statement
wkc15119.pdf Joint Certification of Readiness
wkc15717.pdf Certification of Readiness and Request to Schedule a Hearing or Settlement Conference
wkc15717_dha.pdf Certificate of Readiness and Request to Schedule A Hearing
wkc15782.pdf Termination Notice of Divided-Workforce
wkc15783.pdf Employer Notice of Divided-Workforce
wkc15784.pdf Employee Leasing Company Notification of a Client Covered under a Master Policy for Small Clients
wkc15785.pdf Wisconsin Proof of Coverage Notice for Small Clients
wkc16804.pdf Work Injury Supplemental Benefit Fund Barred Claim
wkc17001.pdf Notice of Potential Eligibility to Receive Vocational Rehabilitation Services
wkc18151.pdf New Insurance or Insurance Change
wkc17843.pdf Fax Cover Sheet - to be used when submitting documents on non-litigated claims.
wkc17876.pdf Annual Report of Permanent Total Disability Payments Made
wkc18-P.pdf BROCHURE - Facts for Injured Workers
wkc18-S-P.pdf BROCHURE - Facts for Injured Workers (Spanish)
wkc7317.pdf BROCHURE - Facts for Employers About WC Law