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  2. Worker's Compensation
  3. Worker's Compensation Forms List

Worker's Compensation Forms List

Advisory statement on the WC forms website:

Forms on this Web Site are the current versions approved by the Worker's Compensation Division. Their use is mandatory.

The Division will not accept forms that:

  1. Have been altered or "customized" in any fashion from the approved version
  2. Are not the current versions
  3. Are not fully and/or accurately completed

Forfeitures for late filing may be assessed if the correct form has not been received on time.

Forms List

Form Form Description
WKC-3-E Medical Treatment Statement - For listing charges from medical providers, or for medicine and supplies.
WKC-7-E Hearing Application - To be filed by a party with the Department requesting resolution of a dispute.
WKC-7 instructions - Instructions for completing Hearing Application (Form WKC-7)
Spanish wkc-7 instructions - Instrucciones Para Llenar La Solicitud de Audiencia Adjunta (Formulario WKC-7)
WKC-7-B-E Compromise Review Application
WKC-12-E Employer's First Report of Injury or Disease - This is a Word file that is protected from modification and enabled for form fill (includes tabbed fields for form completion).
WKC-13-E Supplementary Report on Accidents and Industrial Diseases - Supplemental report to be filed by the insurer or self-insured employer when payments are started, stopped, suspended or changed. This version is protected from modification and enabled for form fill (includes tabbed fields for form completion). This is a Word document.
WKC-13A-E This form is to be used for injuries occurring before April 10, 2022. This form is to be filed with the department by the insurer or self-insured employer when the wage used is less than the maximum compensation rate. Except for fatal, perm total and litigated claims the information on this form must be sent to the WC Division electronically.
WKC-13-A1-E This form is to be used for injuries occurring on or after April 10, 2022. This form is to be filed with the department by the insurer or self-insured employer when the wage used is less than the maximum compensation rate. Except for fatal, perm total and litigated claims the information on this form must be sent to the WC Division electronically.
WKC-16-E Medical Report on Industrial Injuries - To be filed by the insurer or self-insured employer when temporary disability exceeds 3 weeks or permanent disability results.
WKC-16-A-E Physician's Report on Eye Injuries
WKC-16-b-E Practitioner's Report on Accident or Industrial Disease in Lieu of Testimony
WKC-17-DHA-E Subpoena
WKC-19-DHA-E Admission to Service and Answer to Application -- To be filed by the respondent insurer or employer with the Department and the party filing application for hearing. Must be filed within 20 days after service of the application to the Department
WKC-28-E This form is to be used by a party to appeal a DWD administrative law judge's order to the Labor and Industry Review Commission. A petition to LIRC can also be filed electronically through LIRC WC Appeal.
WKC-28-DHA-E This form is to be used by a party to appeal a DHA administrative law judge's order to the Labor and Industry Review Commission. A petition to LIRC can also be filed electronically through LIRC WC Appeal.
WKC-136-E Advance or Lump Sum Request
WKC-140-E Supplemental Payments Reimbursement Request
WKC-170-E Third Party Proceeds Agreement - To be filed by the insurance carrier with the Department for approval of distribution.
WKC-176-E Compromise Agreement - To be filed by the parties with the Department for approval of compensation resolving a dispute.
WKC-177-E Stipulation
WKC-6119 Social Security Reverse Offset Worksheet
WKC-6156 Social Security Information Request
WKC-6743-E Vocational Expert Verified Report
WKC-7359-E Instructions and worksheet to calculate Temporary Partial Disability Payments.
WKC-7602-E Corporate Officer Option Notice
WKC-9351-E Health Service Data Base Certification Application: To be completed by a database company to obtain certification for a health service fee database used for resolving reasonableness of fee disputes
WKC-9380-E Necessity of Treatment Dispute Resolution Request Form
WKC-9488-E Consent Form for Release of Medical Information - This is an electronic format which may be completed on-line and printed for signatures.
WKC-9498 Reasonableness of Fee Dispute Resolution Request Form - This form should be used ONLY for fee disputes related to treatment provided on or after July 1, 1992.
WKC-10042-E Private Vocational Rehabilitation Specialist Certification Application
WKC-10146-E Notification of Vocational Services
WKC-10369-E Private Vocational Rehabilitation Services Quarterly Report
WKC-12698 Self-Restriction Statement
WKC-15119-E Joint Certificate of Readiness
WKC-15717-E Certification of Readiness - The submission of a Certification of Readiness for Hearing by the parties is a representation that the matter is ready for a Hearing or Settlement Conference.
WKC-15782-E Termination Notice of Divided-Workforce
WKC-15783-E Employer Notice of Divided-Workforce
WKC-15784-E Employee Leasing Company Notification of a client covered under a master policy for small clients
WKC-15785-E Wisconsin Proof of Coverage Notice under a master policy for small clients
WKC-16804-E Work Injury Supplemental Benefit Fund Barred Claim
WKC-17001 Notice of Potential Eligibility to Receive Vocational Rehabilitation Services
WKC-17843-E Fax Cover Sheet--To be used when submitting documents on non-litigated claims.
WKC-17876-E Annual Report of Permanent Total Disability Payments Made
WKC-18151-E This form is used for collecting pertinent information from new Worker's Compensation insurance carriers as well as updating changes in information. The form also provides a section to submit or update information pertinent to Third Party Administrators.
WKC-18613-E
 Mileage Reimbursement Record - Complete this form to receive mileage reimbursement for travel to obtain treatment or attend vocational rehabilitation training due to a worker's compensation claim.

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