Free Department of Workforce Development - Wisconsin

Department of Workforce Development
Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Imaging Server Fax: (608) 260-2503 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.wisconsin.gov/wc e-mail: [email protected]

Supplemental Payments Reimbursement Request

Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].

To: Department of Workforce Development, Worker's Compensation Division Request is made for reimbursement of supplemental benefits paid during the preceding calendar year under the provisions of s.102.44(1), Wisconsin Statutes, in the following case and in the amount indicated.
WC Claim Number Employee Name

Employee Social Security Number

Employer Name

Injury Date (MM/dd/yyyy)

Insurance Company Name

u
Weekly Supplemental Rate

Begin Date (MM/dd/yyyy)

End Date (MM/dd/yyyy)

Number of Weeks and Days

Amount of Reimbursement Requested

Weeks: Days: Weeks: Days: Weeks: Days: Weeks: Days:

Total: $0.00

I certify the above amount requested for reimbursement is true and correct and was paid during the preceding calendar year.
Name of Carrier or Exempt Employer to Whom Check Should be Mailed Signed by FEIN Number Mailing Address (Number, Street, City, State, Zip Code) Title Telephone Number Date Signed (MM/dd/yyyy)

(
WKC-140 (R. 03/2009)

)

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Ext.