Advance or Lump Sum Request

Document Number: WKC-136-E

Description: This form is used when an injured worker needs to request an advancement on their permanent disability benefit or from a restricted account. The information provided is used by the division to determine if the advancement request can be approved as specified in the Worker's Compensation Act.

Comments: This form can be filled out on the computer as a fillable pdf.

Content Contact: Lynn Weinberger

Document Attachment: WKC-136-E (Electronic version - pdf/1016 KB)

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