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Wisconsin Department of Workforce Development |
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Advisory statement on the WC forms website:
Forms on this Web Site are the current versions approved by the Worker's Compensation Division. Their use is mandatory.
The Division will not accept forms that:
Have been altered or "customized" in any fashion from the approved version
Are not the current versions
Are not fully and/or accurately completed
Forfeitures for late filing may be assessed if the correct form has not been received on time.
Please order the following form on-line or by calling (608) 266-1340. Please provide your complete mailing address.
| Form Number | Form Description |
|---|---|
| WKC-7
Instructions |
Hearing Application -- To be filed by a party with the Department requesting resolution
of a dispute. (R. 06/2007) |
| Form Number |
Form Description |
|---|---|
| WKC-3-E (R. 01/2009) |
Medical Treatment Statement -- For listing charges from medical providers, or for medicine and supplies. |
| WKC-7-B (R. 03/2009) |
Compromise Review Application |
| WKC-12-E (R. 02/2009) |
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 (R. 03/2009) |
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(R. 02/2009) | 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 (R. 06/2009) |
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 (12/2009) |
Physician's Report on Eye Injuries Printable version WKC-16-A (R. 12/2009) |
|
WKC-16-B-E (12/2009) |
Practitioner's
Report on Accident or Industrial Disease in Lieu of Testimony Printable version WKC-16-B (R. 12/2009) |
| WKC-17 (R. 10/2009) |
Subpoena |
| WKC-19 (R. 01/2009) |
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 (R. 02/2009) |
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 (R. 07/2001) |
License Application |
| WKC-35 (R. 10/2009) |
WC Hearing Appearance Permit Application |
| WKC-140 (R. 03/2009) |
Supplemental Payments Reimbursement Request |
| WKC-170 (R. 10/2009) |
Third Party Proceeds Agreement -- To be filed by the insurance carrier with the Department for approval of distribution. |
| WKC-176 (R. 10/2009) |
Compromise Agreement -- To be filed by the parties with the Department for approval of compensation resolving a dispute. |
| WKC-177 (R. 10/2009) |
Stipulation |
| WKC-6119 (R. 10/2009) |
Social Security Reverse Offset Worksheet |
| WKC-6156 (R. 10/2009) |
Social Security Information Request |
| WKC-6743 (R. 10/2009) |
Vocational Expert Verified Report |
| WKC-7359-E (R. 02/2009) |
Instructions and worksheet to calculate Temporary Partial Disability Payments. |
| WKC-7602 (R. 02/2009) |
Corporate Officer Option Notice |
| WKC-9380 (R. 10/2009) |
Necessity of Treatment Dispute Resolution Request Form |
| WKC-9488-E(R. 04/2009) | Consent Form for Release of Medical Information - This is an electronic format which may be completed on-line and printed for signatures. |
| WKC-9498(R. 11/2004) | 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(R. 10/2006) | Private Vocational Rehabilitation Specialist Certification Application |
| WKC-10146(R. 11/2009) | Notification of Services |
| WKC-10369(R. 12/2009) | Private Vocational Rehabilitation Services Quarterly Report |
| WKC-12698(R. 03/2009) | Self-Restriction Statement |
| WKC-15119-E (R. 01/2009) |
Joint Certificate of Readiness |
|
WKC-15717-E (R. 01/2009) |
Certification of Readiness |
|
WKC-15782-E (N. 08/2009) |
Termination Notice of Divided-Workforce |
|
WKC-15783-E (N. 08/2009) |
Employer Notice of Divided-Workforce |
|
WKC-15784-E (N. 04/2008) |
Employee Leasing Company Notification of a client covered under a master policy for small clients |
|
WKC-15785-E (N. 04/2008) |
Wisconsin Proof of Coverage Notice under a master policy for small clients |
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