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  2. Forms Repository
  3. WKC-16804-E, Work Injury Supplemental Benefit Fund Barred Claim

Work Injury Supplemental Benefit Fund Barred Claim

Document Number: WKC-16804-E

Description: This form is to be completed by an employee or their attorney for initiating barred claims against the Work Injury Supplemental Fund.

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, an electronic pdf file has been provided for your convenience.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-16804-E (Electronic Version - Word/68 KB)

WKC-16804-E (Electronic Version - pdf/816 KB)

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

Contact Information

For questions about this form, or if you need this form in an alternate format, please see the Content Contact (listed to the left)

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