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Supplementary Report on Accidents and Industrial Diseases

Document Number:  WKC-13-E

Description:  Supplemental report to be filed by the insurer or self-insured employer when payments are started, stopped, suspended or changed.

Comments:  This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word).  Except for fatal, perm total and litigated claims, as well as claims with social security offset and ttd non-escalating, the information on this form must be sent to the WC Division electronically.

Content Contact:  Don Martin

Document Attachment:  WKC-13-E (Word/78 KB)

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