Wisconsin > Workers Comp
Supplemental Payments Reimbursement Request WKC-140 - Wisconsin
| Supplemental Payments Reimbursement Request Form. This is a Wisconsin form and can be used in Workers Comp . |
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Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Imaging Server Fax: (608) 260-2503 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: DWDDWC@dwd.state.wi.us Supplemental Payments Reimbursement Request The provision of your social security number is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [(Privacy Law, s. 15.04(1)(m)]. To: Department of Workforce Development, Worker's Compensation Division Request is made for reimbursement of supplemental benefits paid during the preceding calendar year under the provisions of s.102.44(1), Wisconsin Statutes, in the following case and in the amount indicated. WC Claim Number Employee Name Employee Social Security Number Employer Name Injury Date (MM/dd/yyyy) Insurance Company Name u Weekly Supplemental Rate Begin Date (MM/dd/yyyy) End Date (MM/dd/yyyy) Number of Weeks and Days Amount of Reimbursement Requested Weeks: Days: Weeks: Days: Weeks: Days: Weeks: Days: Total: $0.00 I certify the above amount requested for reimbursement is true and correct and was paid during the preceding calendar year. Name of Carrier or Exempt Employer to Whom Check Should be Mailed Signed by FEIN Number Mailing Address (Number, Street, City, State, Zip Code) Title Telephone Number Date Signed (MM/dd/yyyy) ( WKC-140-E (R. 07/2008) ) - Ext. American LegalNet, Inc. www.FormsWorkflow.com
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