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Document Number: WKC-12-E
Description: This form is for the employer to report every work-related injury to its insurance company. If an employee is out more than 3 days due to a work-related injury, or there is PPD, a copy is to be sent to the Worker's Compensation Division by the employer's worker's compensation insurance carrier, not by the employer (unless the claim is a fatality). Except for fatalities, the information on this form must be sent electronically by the employer's worker's compensation carrier to the WC Division.
Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). We are also providing a PDF (WKC-12) which you can print and complete by hand.
Content Contact: Lynn Weinberger
WKC-12-E (English Electronic Version - Word/107 KB)
WKC-12 (English Print Version - pdf/111 KB)
WKC-12-E-S (Spanish Electronic Version - Word/111 KB)
WKC-12-S (Spanish Print Version - pdf/117 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.