Contact Information
 Website  Division of Worker's Compensation
 Email  Bureau of Claims Management
Below is the element requirement table for electronic supplemental 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 


SUPPLEMENTAL REPORT (WKC13) FORMAT 

REVISED 04/13/2000 

REQUIREMENTS BY MAINTENANCE TYPE CODE  IAIABC RELEASE 1 SUBSEQUENT RPT OF INJURY (A49) 

IAIABC 
IAIABC 
IAIABC 
IAIABC 
POSITIONS 
MTC REQUIREMENTS 

GROUPING 
DN 
DATA ELEMENT NAME 
FORMAT 
BEG 
END 
02 
CO 
FN 
IP 
S1 
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 
CLAIM 
0006 
Insurer FEIN 
9 A/N 
16 
24 
M 
M 
M 
M 
M 

0008 
Third Party Administrator FEIN 
9 A/N 
25 
33 
C 
C 
C 
C 
C 

0014 
Claim Administrator Postal Code 
9 A/N 
34 
42 
C 
C 
C 
C 
C 

0042 
Social Security Number 
9 A/N 
43 
51 
M 
M 
M 
M 
M 

0055 
Number of Dependents 
2 N 
52 
53 
O 
O 
O 
O 
O 

0069 
PreExisting Disability 
1 A/N 
54 
54 
O 
O 
O 
O 
O 

0056 
Date Disability Began 
DATE 
55 
62 
M 
M 
M 
M 
M 

0070 
Date of Maximum Medical Improvement 
DATE 
63 
70 
C 
C 
C 
C 
C 

0071 
Return to Work Qualifier 
1 A/N 
71 
71 
C 
C 
C 
C 
C 

0072 
Date of Return/Release to Work 
DATE 
72 
79 
O 
O 
M 
O 
M 

0057 
Employee Date of Death 
DATE 
80 
87 
C 
C 
C 
C 
C 
WAGE 
0062 
Wage 
$9.2 
88 
98 
M 
M 
M 
M 
M 

0063 
Wage Period 
2 A/N 
99 
100 
M 
M 
M 
M 
M 

0064 
Number of Days Worked 
1 N 
101 
101 
O 
O 
O 
O 
O 

0067 
Salary Continued Indicator 
1 A/N 
102 
102 
M 
M 
M 
M 
M 
ACCIDENT 
0031 
Date of Injury 
DATE 
103 
110 
M 
M 
M 
M 
M 

0026 
Insured Report Number 
25 A/N 
111 
135 
O 
O 
O 
O 
O 

0015 
Claim Administrator Claim Number 
25 A/N 
136 
160 
C 
C 
C 
C 
C 

0005 
Agency Claim Number 
25 A/N 
161 
185 
C 
C 
C 
C 
C 
CLAIM STATUS 
0073 
Claim Status 
1 A/N 
186 
186 
O 
O 
O 
O 
O 

0074 
Claim Type 
1 A/N 
187 
187 
O 
O 
O 
O 
O 

0075 
Agreement to Compensate Code 
1 A/N 
188 
188 
O 
O 
O 
O 
O 

0076 
Date of Representation 
DATE 
189 
196 
O 
O 
O 
O 
O 
PAYMENTS 
0077 
Late Reason Code 
2 A/N 
197 
198 
C 
C 
C 
C 
C 
VARIABLE 
0078 
Number of Permanent Impairments 
2 N 
199 
200 
M 
M 
M 
M 
M 

0079 
Number of Payments/Adjustments 
2 N 
201 
202 
M 
M 
M 
M 
M 

0080 
Number of Benefit Adjustments 
2 N 
203 
204 
M 
M 
M 
M 
M 

0081 
Number of Paid to Date/Reduced Earnings/Recoveries 
2 N 
205 
206 
M 
M 
M 
M 
M 

0082 
Number of Death Dependent/Payee Relationships 
2 N 
207 
208 
M 
M 
M 
M 
M 
VARIABLE 
Permanent Impairments Occurs Number of Permanent Impairments times. 


0083 
Permanent Impairment Body Part Code 
3 A/N 
1 
3 
C 
C 
C 
C 
C 

0084 
Permanent Impairment Percentage 
3.2 N 
4 
8 
C 
C 
C 
C 
C 

Payment/Adjustments Occurs Number of Payment/Adjustments times. 


0085 
Payment/Adjustment Code 
3 A/N 
1 
3 
M 
M 
M 
M 
M 

0086 
Payment/Adjustment Paid to Date 
$9.2 
4 
14 
M 
M 
M 
M 
M 

0087 
Payment/Adjustment Weekly Amount 
$9.2 
15 
25 
C 
C 
C 
C 
C 

0088 
Payment/Adjustment Start Date 
DATE 
26 
33 
C 
C 
C 
C 
C 

0089 
Payment/Adjustment End Date 
DATE 
34 
41 
C 
C 
C 
C 
C 

0090 
Payment/Adjustment Weeks Paid 
4 N 
42 
45 
C 
C 
C 
C 
C 

0091 
Payment/Adjustment Days Paid 
1 N 
46 
46 
C 
C 
C 
C 
C 

Benefit Adjustments Occurs Number of Benefit Adjustments times. 


0092 
Benefit Adjustment Code 
4 A/N 
1 
4 
C 
C 
C 
C 
C 

0093 
Benefit Adjustment Weekly Amount 
$9.2 
5 
15 
C 
C 
C 
C 
C 

0094 
Benefit Adjustment Start Date 
DATE 
16 
23 
C 
C 
C 
C 
C 

Paid to Date/Reduced Earnings/Recoveries Occurs Number of Paid to Date/Reduced Earning/Recoveries times. 


0095 
Paid To Date/Reduced Earnings/Recoveries Code 
3 A/N 
1 
3 
C 
C 
C 
C 
C 

0096 
Paid To Date/Reduced Earnings/Recoveries Amount 
$9.2 
4 
14 
C 
C 
C 
C 
C 

Death Dependent/Payee Relationship Occurs Number of Death Dependent/Payee Relationship times. 


0097 
Dependent/Payee Relationship 
2 A/N 
1 
2 
C 
C 
C 
C 
C 