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.
Document Number: WKC-6743-E
Description: This form is used to establish loss of earning capacity.
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-6743) which you can print and complete by hand.
Content Contact: Lynn Weinberger
Document Attachments:
WKC-6743-E (Electronic Version - Word/66 KB)
WKC-6743 (Print Version - pdf/147 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.
DWD Contact Information
201 E. Washington Ave
P.O. Box 7946
Madison, WI 53707
(608) 266-3131
Sign up for DWD news and updates
A proud partner of the 
network