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). If you do not have Microsoft Word we are providing a PDF (WKC-12698) which you can print and complete by hand.
Content Contact: Lynn Weinberger
WKC-12698-E (Electronic Version - Word/45 KB)
WKC-12698 (Print Version - pdf/24 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.