Medical Report on Industrial Injury
Document Number: WKC-16-E
Description: This form is to be filed by the insurer or self-insured employer when temporary disability exceeds 3 weeks or permanent disability results.
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-16) which you can print and complete by hand.
Content Contact: Kathy Froehlich
WKC-16-E (Electronic Version - Word/129 KB)
WKC-16 (Print Version - pdf/76 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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