Work Injury Supplemental Benefit Fund Barred Claim

Document Number:  WKC-16804-E

Description:  This form is to be completed by an employee or their attorney for initiating barred claims against the Work Injury Supplemental Fund.

Comments:  This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). If you do not have Microsoft Word we have also provided a pdf file for you to print and complete by hand.

Content Contact:  Lynn Weinberger

Document Attachments:

WKC-16804-E (Electronic Version - Word/67 KB)

WKC-16804 (Print Version - pdf/185 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.

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