Document Number: WKC-16-A-E
Description: This form is to be filed by the insurer or self-insured employer when temporary disability exceeds 3 weeks or permanent disability results.
Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word).
Content Contact: Lynn Weinberger
WKC-16-A-E (Electronic Version - Word/144 KB)
WKC-16-A (Print Version - pdf/210 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.