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  2. Worker's Compensation
  3. Insurers and Self-Insurers
  4. WKC-12 - First Report of Injury

WKC-12 - First Report of Injury

Format | FAQs

The electronic first reports of injury for the Wisconsin Worker’s Compensation contains data fields that are mandatory, optional and conditional depending on different maintenance type codes.  The format for this information is provided for your convenience.  For your reference, we have provided supplemental information in a frequently asked question mode.

EDI Format

Below is the element requirement table for electronic first 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).

First Report (WKC-12) Format

Revised 08/15/2000

Requirements by maintenance type code - IAIABC Release 1 First Report of Injury (148)
IAIABC IAIABC IAIABC IAIABC POSITIONS MTC REQUIREMENTS
GROUPING DN DATA ELEMENT NAME FORMAT BEG END 00 01 02 04 CO
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
0005 Agency Claim Number 25 A/N 16 40 C C C C C
CLAIM ADMINISTRATOR 0006 Insurer FEIN 9 A/N 41 49 M M M M M
0007 Insurer Name 30 A/N 50 79 M M M M M
0008 Third Party Administrator FEIN 9 A/N 80 88 O O O O O
0009 Third Party Administrator Name 30 A/N 89 118 O O O O O
0010 Claim Administrator Address Line 1 30 A/N 119 148 O O O O O
0011 Claim Administrator Address Line 2 30 A/N 149 178 O O O O O
0012 Claim Administrator City 15 A/N 179 193 C C C C C
0013 Claim Administrator State 2 A/N 194 195 C C C C C
0014 Claim Administrator Postal Code 9 A/N 196 204 M M M M M
0015 Claim Administrator Claim Number 25 A/N 205 229 O O O O O
INSURED 0016 Employer FEIN 9 A/N 230 238 M M M M M
0017 Insured Name 30 A/N 239 268 C C C C C
0018 Employer Name 30 A/N 269 298 M M M M M
0019 Employer Address Line 1 30 A/N 299 328 M M M M M
0020 Employer Address Line 2 30 A/N 329 358 C C C C C
0021 Employer City 15 A/N 359 373 M M M M M
0022 Employer State 2 A/N 374 375 M M M M M
0023 Employer Postal Code 9 A/N 376 384 M M M M M
0024 Self Insured Indicator 1 A/N 385 385 O O O O O
0025 NAICS Code 6 A/N 386 391 C C C C C
0026 Insured Report Number 10 A/N 392 401 O O O O O
0027 Insured Location Number 15 A/N 402 416 O O O O O
POLICY 0028 Policy Number 30 A/N 417 446 O O O O O
0029 Policy Effective Date DATE 447 454 O O O O O
0030 Policy Expiration Date DATE 455 462 O O O O O
ACCIDENT 0031 Date of Injury DATE 463 470 M M M M M
0032 Time of Injury HHMM 471 474 C C C C C
0033 Postal Code of Injury Site 9 A/N 475 483 C C C C C
0034 Employers Premisis Indicator 1 A/N 484 484 O O O O O
0035 Nature of Injury Code 2 A/N 485 486 M M M M M
0036 Part of Body Injured Code 2 A/N 487 488 M M M M M
0037 Cause of Injury Code 2 A/N 489 490 M M M M M
0038 Accident Description/Cause 150 A/N 491 640 M M M M M
0039 Initial Treatment 2 A/N 641 642 O O O O O
0040 Date Reported to Employer DATE 643 650 O O O O O
0041 Date Reported to Claim Administrator DATE 651 658 O O O O O
EMPLOYEE 0042 Social Security Number 9 A/N 659 667 M M M M M
0043 Employee Last Name 30 A/N 668 697 M M M M M
0044 Employee First Name 15 A/N 698 712 M M M M M
0045 Employee Middle Initial 1 A/N 713 713 O O O O O
0046 Employee Address Line 1 30 A/N 714 743 M M M M M
0047 Employee Address Line 2 30 A/N 744 773 C C C C C
0048 Employee City 15 A/N 774 788 M M M M M
0049 Employee State 2 A/N 789 790 M M M M M
0050 Employee Postal Code 9 A/N 791 799 M M M M M
0051 Employee Phone 10 A/N 800 809 C C C C C
0052 Employee Date of Birth DATE 810 817 C C C C C
0053 Gender Code 1 A/N 818 818 M M M M M
0054 Marital Status Code 1 A/N 819 819 O O O O O
0055 Number of Dependents 2 N 820 821 O O O O O
0056 Date Disability Began DATE 822 829 C C C C C
0057 Employee Date of Death DATE 830 837 C C C C C
EMPLOYMENT 0058 Employment Status Code 2 A/N 838 839 O O O O O
0059 Class Code 4 A/N 840 843 O O O O O
0060 Occupation Description 30 A/N 844 873 M M M M M
0061 Date of Hire DATE 874 881 C C C C C
0062 Wage $9.2 882 892 C C C C C
0063 Wage Period 2 A/N 893 894 C C C C C
0064 Number Days Worked 1 N 895 895 O O O O O
0065 Date Last Day Worked DATE 896 903 C C C C C
0066 Full Wages Paid for Date of Injury Indicator 1 A/N 904 904 O O O O O
0067 Salary Continued Indicator 1 A/N 905 905 C C C C C
0068 Date of Return to Work DATE 906 913 C C C C C

First Report (WKC-12) FAQs

You will have to contact the EDI Coordinator directly. He or she can then make the necessary changes to the claim.

We only want you to send in claims where the employee missed more than three (3) days of work, not including a Sunday, or where there will be Permanent Partial Disability (PPD) to be assessed and paid at a later date. This is the same standard as Internet first reports of injury.

If it is discovered that the claim is NLT and there will be no PPD, you can send in a 148 01 for the claim. We interpret the 01 transaction code as no lost time, and we will close out the claim on our system as such if there are no actions required by our staff. If the claim cannot be closed, the EDI Coordinator will review the claim and take necessary action to close the no lost time claim.

You can send an A49 IP for this claim; our load program will automatically reopen the claim and load the initial payment information. In a scenario where the claim was previously denied (148 04), an A49 IP transmission will also reopen the claim since we take this as an indication that liability has now been accepted.

Both the First Report and Initial Payment (IP) transmissions must be sent within 14 days after the Last Day Worked (LDW). If you send data Friday night, we will load it to the database on Monday but use Friday’s date as the date received.

No, you do not need to send these at the same time, since we process all of the 148 transmissions first and then all of the A49 transmissions.

EDI Resources

For more information about EDI Worker's Compensation you can e-mail the EDI Coordinator or call (608) 266-1340.

Contact Information

If you have questions or comments regarding any information on the Worker's Compensation website or need an alternate format, you may contact us at:

(608) 266-1340

dwddwc@dwd.wisconsin.gov

201 E. Washington Ave.
Madison, WI 53703