Supplementary Report on Accidents and Industrial Diseases

Document Number:  WKC-13-E

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

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-13) which you can print and complete by hand.

Content Contact:  Kathy Froehlich

Document Attachments:

WKC-13-E (Electronic Version - Word/112 KB)

WKC-13 (Print Version - pdf/66 KB)

*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.

*** Should you require the necessary software to view the above attachment, please go to the DWD Viewers Download Page.  Links to each specific vendor's site have been provided for you.  Thank you.