Statement Of Self Restriction To Part Time Work {WKC-12698}

WKC-12698-E - STATEMENT OF SELF-RESTRICTION TO PART-TIME WORK. This form should be filed by an injured worker who limited themselves to part-time work. This form is for an injured worker to advise Worker's Compensation whether or not they were self employed or worked for someone else. This form is used by the Wisconsin Department of Workforce Development’s Worker’s Compensation Division to gather information needed to properly calculate an injured worker’s wage for worker’s compensation benefits. It asks the employee to disclose whether, at the time of injury, they had restricted themselves to part-time work or to working only for the employer where the injury occurred. The form also requests information about any additional employment or self-employment the worker may have had at the time of injury. By completing and returning this form to the insurance carrier or self-insured employer, the worker helps ensure accurate computation of benefits under Chapter 102 of the Wisconsin Statutes. While completion of the form is voluntary, failing to provide the information may delay the administration of worker’s compensation benefits. www.FormsWorkflow.com