Work Injury Supplemental Benefit Fund Barred Claim {WKC-16804}

WKC-16804-E - WORK INJURY SUPPLEMENTAL BENEFIT FUND BARRED CLAIM. This form is to be completed by an employee or their attorney for initiating barred claims against the Work Injury Supplemental Fund. The form is used to report traumatic or occupational injury claims that are barred for benefits under the Work Injury Supplemental Benefit Fund. This form must be filed with a WKC-7 Hearing Application as required by the Department of Workforce Development (DWD), Division of Worker’s Compensation, in compliance with Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007. The form collects detailed information about the injured employee, including personal details, Social Security Number, date of injury, date of incident as defined by CMS, description and nature of the injury, any related surgeries, and applicable diagnosis codes. It also requires information about prior worker’s compensation benefits received and the responsible insurance carrier or self-insured employer. The form ensures that all mandatory reporting requirements are met, allowing the DWD to process barred claims accurately while maintaining compliance with federal reporting standards. Completion of the form is crucial for proper administration of Chapter 102 of the Wisconsin Statutes and for timely handling of claims, though failure to provide complete information may result in delays. www.FormsWorkflow.com