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-9380-E) is also provided for your convenience.
Content Contact: Lynn Weinberger
WKC-12698-E (Electronic Version - Word/45 KB)
WKC-12698-E (Electronic Version - pdf/24 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.