Document Number: WKC-140-E
Description: This is a request by an Insurance Carrier or Self-Insured Employer for reimbursement of supplemental benefits.
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 we are providing a PDF (WKC-140) which you can print and complete by hand.
Content Contact: Lynn Weinberger
WKC-140-E (Electronic Version - Word/62 KB)
WKC-140 (Print Version - pdf/132 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.