Employers First Report Of Injury Or Disease {WKC-12-E}

WKC-12 - EMPLOYER’S FIRST REPORT OF INJURY OR DISEASE. This form is used by Wisconsin employers to report workplace injuries or occupational illnesses to comply with the state’s Worker’s Compensation Act (Chapter 102, Wis. Stats.). This form is required when an employee suffers an injury that results in death or disability beyond the three-day waiting period. For fatal injuries, the employer must notify both the Department of Workforce Development (DWD) and their insurance carrier within one day of the employee's death. For non-fatal injuries involving lost time, the employer must report the injury to their insurer within seven days. If the employer is self-insured, they must report electronically to the DWD within 14 days of the injury or onset of disability. This form gathers information such as the employee’s identity and employment details, the employer’s insurance information, wage data, a description of the incident, and the nature of the injury. www.FormsWorkflow.com