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Annual Report of Permanent Total Disability Payments Made

Document Number: WKC-17876-E

Description: This form is used for meeting the reporting requirements per s. DWD80.02 (2)(k) Wisconsin Administrative Code.

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-17876) which you can print and complete by hand.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-17876-E (Electronic Version - Word/62 KB)

WKC-17876 (Print Version - pdf/105 KB)

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