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Document Number: WKC-12698-E
Description: This form should be filed by an injured worker who limited themselves to part-time work. This form is for an injured worker to advise Worker's Compensation whether or not they were self employed or worked for someone else.
Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). An electronic PDF (WKC-12698-E) is also provided for your convenience.
Content Contact: Lynn Weinberger
Document Attachments:
WKC-12698-E (English Electronic Version - Word/41 KB)
WKC-12698-E (English Electronic Version - pdf/702 KB)
WKC-12698-E-S (Spanish Electronic Version - Word/56 KB)
WKC-12698-E-S (Spanish Electronic Version - pdf/783 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.
DWD Contact Information
201 E. Washington Ave
P.O. Box 7946
Madison, WI 53707
(608) 266-3131
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