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Supplemental Payments Reimbursement Request

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

Document Attachments:

WKC-140-E (Electronic Version - Word/66 KB)

WKC-140-E (Electronic Version - pdf/113 KB)

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