Document Number: WKC-13-A-E
Description: This form is to be filed with the department by the insurer or self-insured employer when the wage used is less than the maximum compensation rate. Except for fatal, perm total and litigated claims the information on this form must be sent to the WC Division electronically.
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-13-A) which you can print and complete by hand.
Content Contact: Lynn Weinberger
WKC-13-A-E (Electronic Version - Word/79 KB)
WKC-13-A (Print Version - pdf/182 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.