Wisconsin Worker's Compensation Notice to Injured Workers and Employers

The State of Wisconsin requires this employer to have worker's compensation insurance coverage.

Both employees and employers have rights and responsibilities under the worker's compensation law.

In Case of Work Injuries

Employee

1. Immediately report any work injury or suspected occupational disease to your supervisor, Human Resources department, or other designated employer representative.
2. Get medical treatment as soon as possible. You have the right to choose your own doctor for work injuries.
3. Give your employer a copy of your doctor's note detailing your work restrictions or taking you off work.

Employer

1. Complete and submit a first report of injury (form WKC-12) to notify your worker's compensation insurance company of any work injury or suspected occupational disease. Fatal claims must be reported within 24 hours.
2. Submit any bills for the injured worker's medical care to your adjuster. Make sure to include the claim number.
3. Let your adjuster know if you will be able to accommodate any restrictions related to the work injury.

This employer's worker's compensation insurance carrier or claim administrator is:

Name of Insurance Carrier or Claim Administrator:
Mailing Address:
City, State, Zip Code:
Telephone Number:

If you have questions about work injuries, please contact:

Worker's Compensation
PO Box 7901
Madison, WI 53707-7901
DWDDWC@dwd.wisconsin.gov
(608) 266-1340

The Department of Workforce Development is an equal opportunity employer and service provider. If you have a disability and need to access this information in an alternate format or need it translated to another language, please contact us.