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Document Number: WKC-140-E
Description: This is a request by an Insurance Carrier or Self-Insured Employer for reimbursement of supplemental benefits.
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-140-E) is also provided for your convenience.
Content Contact: Lynn Weinberger
WKC-140-E (Electronic Version - Word/62 KB)
WKC-140-E (Electronic Version - pdf/132 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.