Skip main navigation

Outdated or Unsupported Browser Detected
DWD's website uses the latest technology. This makes our site faster and easier to use across all devices. Unfortunatley, your browser is out of date and is not supported. An update is not required, but it is strongly recommended to improve your browsing experience. To update Internet Explorer to Microsoft Edge visit their website.

  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/791 KB)

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

Contact Information