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Document Number: WKC-17001-E
Description: This form is sent by an insurance carrier to the injured worker notifying them of potential eligibility for services from DVR.
Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). We are also providing a PDF (WKC-17001) which you can print and complete by hand.
Content Contact: Lynn Weinberger
Document Attachments:
WKC-17001-E (Electronic Version - Word/57 KB)
WKC-17001 (Print Version - pdf/59 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.
DWD Contact Information
201 E. Washington Ave
P.O. Box 7946
Madison, WI 53707
(608) 266-3131
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