Fill and Sign the Wi Workers Compensation Form

Employer Name Diagnosed Disability/injury Employee's Work Restrictions/Limitations Insurance Company Mailing Address (Number, Street, City, State, Zip Code) Agency Name Mailing Address (Number, Street, City, State, Zip Code) Vocational Rehabilitation Specialist Signature Date Case Opened Preparer's Printed Name Date Case Prepared                                                                                                                             Vocational Evaluation Retraining Plan Development Job Placement Other (Describe)                         ( ) ( ) ( ) Wisconsin Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 NOTIFICATION OF SERVICES Personal information you provide may be used for secondary purposes Privacy Law, s. 15.04(1)(m) WC Claim Number Employee Name Social Security Number Employee Address (Number, Street, City, State, Zip Code) EMPLOYEE Injury Date Date of Birth Telephone Number INSURER Claim Representative Telephone Number Name VOCATIONAL WCD Certification Number Telephone Number REHABILITATION SPECIALIST Check Services Planned: This is notification that I have been selected by the above-named individual to provide necessary vocational rehabilitation services to help that individual return to work. Return completed copy: One to insurance company (or self-insured employer) and one copy to Worker's Compensation Division. WKC-10146 (R. 09/2000)