First Report (WKC-12) Format

Below is the event table for electronic first reports being sent to State of Wisconsin, Worker’s Compensation.  It will detail what fields are mandatory, conditional and optional for the various maintenance type codes (MTC) that we accept.

*NOTE: If a code does not exist in the MTC Requirements, then WC does not accept that code.
MTC Requirements are: M(mandatory), C(conditional) or O(optional).

STATE OF WISCONSIN

FIRST REPORT (WKC-12) FORMAT

REVISED 08/15/2000

REQUIREMENTS BY MAINTENANCE TYPE CODE - IAIABC RELEASE 1 FIRST REPORT OF INJURY (148)

IAIABC

IAIABC

IAIABC

IAIABC

POSITIONS

MTC REQUIREMENTS

GROUPING

DN

DATA ELEMENT NAME

FORMAT

BEG

END

00

01

02

04

CO

TRANSACTION

0001

Transaction Set ID

3 A/N

1

3

M

M

M

M

M

 

0002

Maintenance Type Code

2 A/N

4

5

M

M

M

M

M

 

0003

Maintenance Type Code Date

DATE

6

13

M

M

M

M

M

JURISDICTION

0004

Jurisdiction

2 A/N

14

15

M

M

M

M

M

 

0005

Agency Claim Number

25 A/N

16

40

C

C

C

C

C

CLAIM ADMINISTRATOR

0006

Insurer FEIN

9 A/N

41

49

M

M

M

M

M

 

0007

Insurer Name

30 A/N

50

79

M

M

M

M

M

 

0008

Third Party Administrator FEIN

9 A/N

80

88

O

O

O

O

O

 

0009

Third Party Administrator Name

30 A/N

89

118

O

O

O

O

O

 

0010

Claim Administrator Address Line 1

30 A/N

119

148

O

O

O

O

O

 

0011

Claim Administrator Address Line 2

30 A/N

149

178

O

O

O

O

O

 

0012

Claim Administrator City

15 A/N

179

193

C

C

C

C

C

 

0013

Claim Administrator State

2 A/N

194

195

C

C

C

C

C

 

0014

Claim Administrator Postal Code

9 A/N

196

204

M

M

M

M

M

 

0015

Claim Administrator Claim Number

25 A/N

205

229

O

O

O

O

O

INSURED

0016

Employer FEIN

9 A/N

230

238

M

M

M

M

M

 

0017

Insured Name

30 A/N

239

268

C

C

C

C

C

 

0018

Employer Name

30 A/N

269

298

M

M

M

M

M

 

0019

Employer Address Line 1

30 A/N

299

328

M

M

M

M

 M

 

0020

Employer Address Line 2

30 A/N

329

358

C

C

C

C

C

 

0021

Employer City

15 A/N

359

373

M

M

M

M

M

 

0022

Employer State

2 A/N

374

375

M

M

M

M

M

 

0023

Employer Postal Code

9 A/N

376

384

M

M

M

M

M

 

0024

Self Insured Indicator

1 A/N

385

385

O

O

O

O

O

 

0025

SIC Code

6 A/N

386

391

C

C

C

C

C

 

0026

Insured Report Number

10 A/N

392

401

O

O

O

O

O

 

0027

Insured Location Number

15 A/N

402

416

O

O

O

O

O

POLICY

0028

Policy Number

30 A/N

417

446

O

O

O

O

O

 

0029

Policy Effective Date

DATE

447

454

O

O

O

O

O

 

0030

Policy Expiration Date

DATE

455

462

O

O

O

O

O

ACCIDENT

0031

Date of Injury

DATE

463

470

M

M

M

M

M

 

0032

Time of Injury

HHMM

471

474

C

C

C

C

C

 

0033

Postal Code of Injury Site

9 A/N

475

483

C

C

C

C

C

 

0034

Employers Premisis Indicator

1 A/N

484

484

O

O

O

O

O

 

0035

Nature of Injury Code

2 A/N

485

486

M

M

M

M

M

 

0036

Part of Body Injured Code

2 A/N

487

488

M

M

M

M

M

 

0037

Cause of Injury Code

2 A/N

489

490

M

M

M

M

M

 

0038

Accident Description/Cause

150 A/N

491

640

M

M

M

M

M

 

0039

Initial Treatment

2 A/N

641

642

O

O

O

O

O

 

0040

Date Reported to Employer

DATE

643

650

O

O

O

O

O

 

0041

Date Reported to Claim Administrator

DATE

651

658

O

O

O

O

O

EMPLOYEE

0042

Social Security Number

9 A/N

659

667

M

M

M

M

M

 

0043

Employee Last Name

30 A/N

668

697

M

M

M

M

M

 

0044

Employee First Name

15 A/N

698

712

M

M

M

M

M

 

0045

Employee Middle Initial

1 A/N

713

713

O

O

O

O

O

 

0046

Employee Address Line 1

30 A/N

714

743

M

M

M

M

M

 

0047

Employee Address Line 2

30 A/N

744

773

C

C

C

C

C

 

0048

Employee City

15 A/N

774

788

M

M

M

M

M

 

0049

Employee State

2 A/N

789

790

M

M

M

M

M

 

0050

Employee Postal Code

9 A/N

791

799

M

M

M

M

M

 

0051

Employee Phone

10 A/N

800

809

C

C

C

C

C

 

0052

Employee Date of Birth

DATE

810

817

C

C

C

C

C

 

0053

Gender Code

1 A/N

818

818

M

M

M

M

M

 

0054

Marital Status Code

1 A/N

819

819

O

O

O

O

O

 

0055

Number of Dependents

2 N

820

821

O

O

O

O

O

 

0056

Date Disability Began

DATE

822

829

C

C

C

C

C

 

0057

Employee Date of Death

DATE

830

837

C

C

C

C

C

EMPLOYMENT

0058

Employment Status Code

2 A/N

838

839

O

O

O

O

O

 

0059

Class Code

4 A/N

840

843

O

O

O

O

O

 

0060

Occupation Description

30 A/N

844

873

M

M

M

M

M

 

0061

Date of Hire

DATE

874

881

C

C

C

C

C

 

0062

Wage

$9.2

882

892

C

C

C

C

C

 

0063

Wage Period

2 A/N

893

894

C

C

C

C

C

 

0064

Number Days Worked

1 N

895

895

O

O

O

O

O

 

0065

Date Last Day Worked

DATE

896

903

C

C

C

C

C

 

0066

Full Wages Paid for Date of Injury Indicator

1 A/N

904

904

O

O

O

O

O

 

0067

Salary Continued Indicator

1 A/N

905

905

C

C

C

C

C

 

0068

Date of Return to Work

DATE

906

913

C

C

C

C

C