Document Number: WKC-16-E
Description: This form is to be filed by the insurer or self-insured employer when temporary disability exceeds 3 weeks or permanent disability results.
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-16) which you can print and complete by hand.
Content Contact: Lynn Weinberger
WKC-16-E (Electronic Version - Word/132 KB)
WKC-16 (Print Version - pdf/181 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.