Supplemental Payments Reimbursement Request
Document Number: WKC-140-E
Description: This is a request by an Insurance Carrier or Self-Insured Employer for reimbursement of supplemental benefits.
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-140) which you can print and complete by hand.
Content Contact: Kathy Froehlich
WKC-140-E (Electronic Version - Word/73 KB)
WKC-140 (Print Version - pdf/11 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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