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
WKC-16804-E (Electronic Version - Word/67 KB)
WKC-16804-E (Electronic Version - pdf/185 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.