Self-Restriction to Part-Time Work
Document Number: WKC-12698-E
Description: 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.
Comments: This form is an electronic Microsoft Word template that can filled out on your computer (if you have Microsoft Word). If you do not have Microsoft Word we are providing a PDF (WKC-12698) which you can print and complete by hand.
Content Contact: Kathy Froehlich
WKC-12698-E (Electronic Version - Word/45 KB)
WKC-12698 (Print Version - pdf/24 KB)
*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.
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