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  2. Forms Repository
  3. WKC-140-E, Supplemental Payments Reimbursement Request

Supplemental Payments Reimbursement Request

Document Number: WKC-140-E

Description: This is a request by an Insurance Carrier or Self-Insured Employer for reimbursement of supplemental benefits.

Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). An electronic PDF (WKC-140-E) is also provided for your convenience.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-140-E (Electronic Version - Word/66 KB)

WKC-140-E (Electronic Version - pdf/160 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.

Contact Information

For questions about this form, or if you need this form in an alternate format, please see the Content Contact (listed to the left)

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