Supplemental Payments Reimbursement Request {WKC-140E}

WKC-140-E - SUPPLEMENTAL PAYMENTS REIMBURSEMENT REQUEST. This form is used by an insurance carrier or self-insured employer to request reimbursement from the Wisconsin Department of Workforce Development for supplemental benefits paid to a worker during the preceding calendar year under the provisions of Section 102.44(1) of the Wisconsin Statutes. The form collects essential information, including the worker’s compensation claim number, employee name, Social Security number, employer and insurance company details, injury date, and the weekly supplemental payment rate. It also requires a detailed account of the dates and number of weeks and days for which supplemental payments were made, as well as the total amount requested for reimbursement. By completing and signing this form, the employer or carrier certifies that the information is accurate and that the reimbursement requested pertains solely to supplemental benefit payments made during the previous calendar year. The completed form is submitted to the Worker’s Compensation Division, which processes the reimbursement payment. www.FormsWorkflow.com