Fill and Sign the Supplemental Payments Reimbursement Request for Workers Compensation Wisconsin Form

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Page             Supplemental Payments Reimbursement Request Department of Workforce Development Worker's Compensation Division 201 E. Washington Avenue, Rm. 161P.O. Box 7901Madison, WI 53707-7901Telephone: (608) 266-1340 To: Department of Workforce Development, Worker's Compensation DivisionRequest is made for reimbursement of supplemental benefits paid during the preceding calendar year under the provisions of s. 102.44(l), Wisconsin Statutes, in the following cases and in the amounts indicated. List alphabetically by injured employee names. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(l)(m)]. Weekl y Time Period Covered and Amount of Injured Employee Employe r Injury Date Supplemental Number of Weeks Reimbursement Rate and Days Requested Total: $ I certify that the above amounts requested for reimbursement are true and correct and they were paid during the preceding calendar year. Name of Carrier or Exempt Employer to Whom Check Should be Mailed Mailing Address (Number, street, city, state, zip code) Signed by Title Date Signed FEIN Number Telephone Number Please forward original and one copy to the return address shown at the top of this form. of WKC-140 (R. 4/97)