Worker's Compensation Forms List

Advisory statement on the WC forms website:

Forms on this Web Site are the current versions approved by the Worker's Compensation Division. Their use is mandatory.

The Division will not accept forms that:

  1. Have been altered or "customized" in any fashion from the approved version
  2. Are not the current versions
  3. Are not fully and/or accurately completed

Forfeitures for late filing may be assessed if the correct form has not been received on time.

Please order the following form on-line or by calling (608) 266-1340. Please provide your complete mailing address.

Form Number Form Description
WKC-7
Instructions
Hearing Application -- To be filed by a party with the Department requesting resolution of a dispute. (R. 04/2013)  Please order the following form on-line or by calling (608) 266-1340. Please provide your complete mailing address.
Form Number Form Description
WKC-3-E
(R. 02/2010)
Medical Treatment Statement -- For listing charges from medical providers, or for medicine and supplies.
WKC-7-B
(R. 03/2009)
Compromise Review Application
WKC-12-E
(R. 02/2009)
Employer's First Report of Injury or Disease -- This is a Word file that is protected from modification and enabled for form fill (includes tabbed fields for form completion).
WKC-13-E
(R. 03/2009)
Supplementary Report on Accidents and Industrial Diseases -- Supplemental report to be filed by the insurer or self-insured employer when payments are started, stopped, suspended or changed. This version is protected from modification and enabled for form fill (includes tabbed fields for form completion). This is a Word document.
WKC-13A-E
(R. 08/2009)
Wage Information -- To be filed with the Department by the insurer or self-insured employer when wage used is less than the maximum compensation rate. This version is protected from modification and enabled for form fill (includes tabbed fields for form completion). This is a Word document.
WKC-16-E
(R. 04/2010)
Medical Report on Industrial Injuries -- To be filed by the insurer or self-insured employer when temporary disability exceeds 3 weeks or permanent disability results.
WKC-16-A-E
(12/2009)
Physician's Report on Eye Injuries Printable version WKC-16-A (R. 12/2009)
WKC-16-B-E
(02/2014)
Practitioner's Report on Accident or Industrial Disease in Lieu of Testimony
WKC-17
(R. 10/2009)
Subpoena
WKC-19-E
(R. 05/2014)
Admission to Service and Answer to Application -- To be filed by the respondent insurer or employer with the Department and the party filing application for hearing. Must be filed within 20 days after service of the application to the Department
WKC-28
(R. 02/2009)
Labor and Industry Review Commission Petition for Review of Findings and Order of Administrative Law Judge -- To be used by a party to appeal administrative law judge's order to the Labor and Industry Review Commission.
WKC-34
(R. 10/2009)
License Application
WKC-35
(R. 10/2009)
WC Hearing Appearance Permit Application
WKC-140-E
(R. 12/2012)
Supplemental Payments Reimbursement Request
WKC-170
(R. 10/2009)
Third Party Proceeds Agreement -- To be filed by the insurance carrier with the Department for approval of distribution.
WKC-176
(R. 10/2009)
Compromise Agreement -- To be filed by the parties with the Department for approval of compensation resolving a dispute.
WKC-177
(R. 10/2009)
Stipulation
WKC-6119
(R. 10/2009)
Social Security Reverse Offset Worksheet
WKC-6156
(N. 11/2011)
Social Security Information Request
WKC-6743
(R. 10/2009)
Vocational Expert Verified Report
WKC-7359-E
(R. 02/2009)
Instructions and worksheet to calculate Temporary Partial Disability Payments.
WKC-7602
(R. 02/2009)
Corporate Officer Option Notice
WKC-9351-E Health Service Data Base Certification Application:
To be completed by a database company to obtain certification for a health service fee database used for resolving reasonableness of fee disputes
WKC-9380-E
(N. 04/2012)
Necessity of Treatment Dispute Resolution Request Form
WKC-9488-E
(R. 03/2009)
Consent Form for Release of Medical Information - This is an electronic format which may be completed on-line and printed for signatures.
WKC-9498
(N. 04/2012)
Reasonableness of Fee Dispute Resolution Request Form -- This form should be used ONLY for fee disputes related to treatment provided on or after July 1, 1992.
WKC-10042
(R. 11/2009)
Private Vocational Rehabilitation Specialist Certification Application
WKC-10146
(R. 11/2009)
Notification of Services
WKC-10369
(R. 12/2009)
Private Vocational Rehabilitation Services Quarterly Report
WKC-12698
(R. 03/2009)
Self-Restriction Statement
WKC-15119-E
(R. 01/2009)
Joint Certificate of Readiness
WKC-15717-E
(R. 11/2011)
Certification of Readiness
WKC-15782-E
(N. 08/2009)
Termination Notice of Divided-Workforce
WKC-15783-E
(N. 08/2009)
Employer Notice of Divided-Workforce
WKC-15784-E
(N. 04/2008)
Employee Leasing Company Notification of a client covered under a master policy for small clients
WKC-15785-E
(N. 04/2009)
Wisconsin Proof of Coverage Notice under a master policy for small clients
WKC-16804-E
(R. 04/2013)
Work Injury Supplemental Benefit Fund Barred Claim
WKC-17001
(N. 07/2011)
Notice of Potential Eligibility to Receive Vocational Rehabilitation Services

You may download the Adobe Acrobat Reader for free. Please see the DWD Viewers Download Page.