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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 protected from modification and enabled for form fill (includes tabbed fields for form completion).

Content Contact:  Don Martin

Document Attachment:  WKC-140-E (Word/69 KB)

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