Contact Information
 Website  Division of Worker's Compensation
 Email  Bureau of Claims Management
Below is the event table for electronic first reports being sent to State of Wisconsin, Worker’s Compensation. It will detail what fields are mandatory, conditional and optional for the various maintenance type codes (MTC) that we accept.
*NOTE: If a code does not
exist in the MTC Requirements, then WC does not accept that code.
MTC Requirements are: M(mandatory), C(conditional)
or O(optional).
STATE OF WISCONSIN 


FIRST REPORT (WKC12) FORMAT 

REVISED 08/15/2000 

REQUIREMENTS BY MAINTENANCE TYPE CODE  IAIABC RELEASE 1 FIRST REPORT OF INJURY (148) 

IAIABC 
IAIABC 
IAIABC 
IAIABC 
POSITIONS 
MTC REQUIREMENTS 

GROUPING 
DN 
DATA ELEMENT NAME 
FORMAT 
BEG 
END 
00 
01 
02 
04 
CO 
TRANSACTION 
0001 
Transaction Set ID 
3 A/N 
1 
3 
M 
M 
M 
M 
M 

0002 
Maintenance Type Code 
2 A/N 
4 
5 
M 
M 
M 
M 
M 

0003 
Maintenance Type Code Date 
DATE 
6 
13 
M 
M 
M 
M 
M 
JURISDICTION 
0004 
Jurisdiction 
2 A/N 
14 
15 
M 
M 
M 
M 
M 

0005 
Agency Claim Number 
25 A/N 
16 
40 
C 
C 
C 
C 
C 
CLAIM ADMINISTRATOR 
0006 
Insurer FEIN 
9 A/N 
41 
49 
M 
M 
M 
M 
M 

0007 
Insurer Name 
30 A/N 
50 
79 
M 
M 
M 
M 
M 

0008 
Third Party Administrator FEIN 
9 A/N 
80 
88 
O 
O 
O 
O 
O 

0009 
Third Party Administrator Name 
30 A/N 
89 
118 
O 
O 
O 
O 
O 

0010 
Claim Administrator Address Line 1 
30 A/N 
119 
148 
O 
O 
O 
O 
O 

0011 
Claim Administrator Address Line 2 
30 A/N 
149 
178 
O 
O 
O 
O 
O 

0012 
Claim Administrator City 
15 A/N 
179 
193 
C 
C 
C 
C 
C 

0013 
Claim Administrator State 
2 A/N 
194 
195 
C 
C 
C 
C 
C 

0014 
Claim Administrator Postal Code 
9 A/N 
196 
204 
M 
M 
M 
M 
M 

0015 
Claim Administrator Claim Number 
25 A/N 
205 
229 
O 
O 
O 
O 
O 
INSURED 
0016 
Employer FEIN 
9 A/N 
230 
238 
M 
M 
M 
M 
M 

0017 
Insured Name 
30 A/N 
239 
268 
C 
C 
C 
C 
C 

0018 
Employer Name 
30 A/N 
269 
298 
M 
M 
M 
M 
M 

0019 
Employer Address Line 1 
30 A/N 
299 
328 
M 
M 
M 
M 
M 

0020 
Employer Address Line 2 
30 A/N 
329 
358 
C 
C 
C 
C 
C 

0021 
Employer City 
15 A/N 
359 
373 
M 
M 
M 
M 
M 

0022 
Employer State 
2 A/N 
374 
375 
M 
M 
M 
M 
M 

0023 
Employer Postal Code 
9 A/N 
376 
384 
M 
M 
M 
M 
M 

0024 
Self Insured Indicator 
1 A/N 
385 
385 
O 
O 
O 
O 
O 

0025 
SIC Code 
6 A/N 
386 
391 
C 
C 
C 
C 
C 

0026 
Insured Report Number 
10 A/N 
392 
401 
O 
O 
O 
O 
O 

0027 
Insured Location Number 
15 A/N 
402 
416 
O 
O 
O 
O 
O 
POLICY 
0028 
Policy Number 
30 A/N 
417 
446 
O 
O 
O 
O 
O 

0029 
Policy Effective Date 
DATE 
447 
454 
O 
O 
O 
O 
O 

0030 
Policy Expiration Date 
DATE 
455 
462 
O 
O 
O 
O 
O 
ACCIDENT 
0031 
Date of Injury 
DATE 
463 
470 
M 
M 
M 
M 
M 

0032 
Time of Injury 
HHMM 
471 
474 
C 
C 
C 
C 
C 

0033 
Postal Code of Injury Site 
9 A/N 
475 
483 
C 
C 
C 
C 
C 

0034 
Employers Premisis Indicator 
1 A/N 
484 
484 
O 
O 
O 
O 
O 

0035 
Nature of Injury Code 
2 A/N 
485 
486 
M 
M 
M 
M 
M 

0036 
Part of Body Injured Code 
2 A/N 
487 
488 
M 
M 
M 
M 
M 

0037 
Cause of Injury Code 
2 A/N 
489 
490 
M 
M 
M 
M 
M 

0038 
Accident Description/Cause 
150 A/N 
491 
640 
M 
M 
M 
M 
M 

0039 
Initial Treatment 
2 A/N 
641 
642 
O 
O 
O 
O 
O 

0040 
Date Reported to Employer 
DATE 
643 
650 
O 
O 
O 
O 
O 

0041 
Date Reported to Claim Administrator 
DATE 
651 
658 
O 
O 
O 
O 
O 
EMPLOYEE 
0042 
Social Security Number 
9 A/N 
659 
667 
M 
M 
M 
M 
M 

0043 
Employee Last Name 
30 A/N 
668 
697 
M 
M 
M 
M 
M 

0044 
Employee First Name 
15 A/N 
698 
712 
M 
M 
M 
M 
M 

0045 
Employee Middle Initial 
1 A/N 
713 
713 
O 
O 
O 
O 
O 

0046 
Employee Address Line 1 
30 A/N 
714 
743 
M 
M 
M 
M 
M 

0047 
Employee Address Line 2 
30 A/N 
744 
773 
C 
C 
C 
C 
C 

0048 
Employee City 
15 A/N 
774 
788 
M 
M 
M 
M 
M 

0049 
Employee State 
2 A/N 
789 
790 
M 
M 
M 
M 
M 

0050 
Employee Postal Code 
9 A/N 
791 
799 
M 
M 
M 
M 
M 

0051 
Employee Phone 
10 A/N 
800 
809 
C 
C 
C 
C 
C 

0052 
Employee Date of Birth 
DATE 
810 
817 
C 
C 
C 
C 
C 

0053 
Gender Code 
1 A/N 
818 
818 
M 
M 
M 
M 
M 

0054 
Marital Status Code 
1 A/N 
819 
819 
O 
O 
O 
O 
O 

0055 
Number of Dependents 
2 N 
820 
821 
O 
O 
O 
O 
O 

0056 
Date Disability Began 
DATE 
822 
829 
C 
C 
C 
C 
C 

0057 
Employee Date of Death 
DATE 
830 
837 
C 
C 
C 
C 
C 
EMPLOYMENT 
0058 
Employment Status Code 
2 A/N 
838 
839 
O 
O 
O 
O 
O 

0059 
Class Code 
4 A/N 
840 
843 
O 
O 
O 
O 
O 

0060 
Occupation Description 
30 A/N 
844 
873 
M 
M 
M 
M 
M 

0061 
Date of Hire 
DATE 
874 
881 
C 
C 
C 
C 
C 

0062 
Wage 
$9.2 
882 
892 
C 
C 
C 
C 
C 

0063 
Wage Period 
2 A/N 
893 
894 
C 
C 
C 
C 
C 

0064 
Number Days Worked 
1 N 
895 
895 
O 
O 
O 
O 
O 

0065 
Date Last Day Worked 
DATE 
896 
903 
C 
C 
C 
C 
C 

0066 
Full Wages Paid for Date of Injury Indicator 
1 A/N 
904 
904 
O 
O 
O 
O 
O 

0067 
Salary Continued Indicator 
1 A/N 
905 
905 
C 
C 
C 
C 
C 

0068 
Date of Return to Work 
DATE 
906 
913 
C 
C 
C 
C 
C 