Supplementary Report on Accidents and Industrial Diseases

Document Number: WKC-13-E

Description: This supplemental report is to be filed by the insurer or self-insured employer when payments are started, stopped, suspended or changed. Except for fatal, perm total and litigated claims, as well as claims with social security offset and ttd non-escalating, 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) which you can print and complete by hand.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-13-E (Electronic Version - Word/99 KB)

WKC-13 (Print Version - pdf/185 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.