Fill and Sign the Wisconsin Workers Compensation Form

SUBMIT THE WKC-12 WITH THIS REPORT IF IT WAS NOT PREVIOUSLY SUBMITTED. The provision of your social security number 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)]. (Please read the instructions on reverse for completing this form.) 1. Name of Injured Employee       2. Social Security Number       3. Address City State Zip Code                         4. Injury Date       5. Last Day Employee Worked       6. Nature of Injury or Illness       7. Employer Name       8. Address (City, State and Zip)       9. Insurance Carrier (Not TPA or Adjuster) Check if employer is self-insured       10. Insurer Claim Number       11. N.A.I.C. Number       12. Insurer’s Claim Handling Address City State Zip Code                         13. Date & Type of First Type: TTD Compensation Payment TPD Salary Cont’d Date:       Other 14. Amount of 1st payment $       15. Weekly Wage Used to Set TTD Rate: $       Rate below max. - WKC-13-A attached WKC-13-A not attached - Estimated date it will be sent is:       16. TTD Rate: $       17. If 1st Payment Was Late, (more than 14 days after injury date) State Reason:       18. Remarks: Denied Suspended -- Suspended -- Other Reason Being Investigated Lack of Medical Information (Attach Copy of Suspension Letter) (Attach Copy of Denial Letter) Date Final Medical Report required under DWD 80.02(2)(e) 4 is anticipated:       Other Remarks (Specify):       Payment Period 19. Type of Payment 20. Last Day of Work 21. Date of Return to Work or End of Healing (Do not enter if TTD or TPD continues to be paid) 22. No. of Employer Paid Holidays 23. No. of Weeks and/or Days Paid 24. Rate 25. Amount of Comp. Paid 26. Accumulated Total Amount Paid TTD TPD Other:                                                 TTD TPD Other:                                                 TTD TPD Other:                                                 TTD TPD Other:                                                 27. Amount of Permanent Partial Disability due: (Attach supporting medical report if not previously submitted.) Indicate amount of PPD paid to date:       Wks. @ $       = $       $       28. Final Indemnity Payment Date Type of Payment:       Date of Payment:       29. Has the worker returned to work with wages at 90% or more of wages at the time of injury? Yes No 30. Report Prepared By       31. Work Phone No. (     )     -      32. Position       33. Date Signed       WKC-13-E (R. 01/2004)SUPPLEMENTARY REPORT ON ACCIDENTS AND INDUSTRIAL DISEASES 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.state.wi.us/wc/ e-mail: DWDDWC@dwd.state.wi.us Under DWD 80.02(2), for injuries which require the first report of injury, self-insured employers and insurance companies shall submit:  A supplementary report on a form WKC-13 on or before 30 days following that on which the injury occurred.  Make a report within 7 days from the date that payments are stopped for any reason. If any payments are stopped for a reason other than the employee’s return to work, provide an explanation to the department and the employee. The insurer shall advise the employee as to the reason for stopping payments, what the employee must do to reinstate payments, and the worker’s rights to a hearing.  Make a report on form WKC-13 with a copy to the employee when payment of compensation is changed from temporary total disability or temporary partial disability to a permanent disability.  Include a copy of the WKC-13-A with the WKC-13 for claims where the wage is less than maximum, or provide an estimated date if the wage information is not available at the time the WKC-13 is submitted.  Make a final report on a form WKC-13 within 30 days of when final payment of any type of compensation has been made. A practitioner’s report is due if temporary disability exceeds 3 weeks or if permanent disability has resulted. The final medical report showing the extent of permanent disability and the end of healing is due within 30 days after the date that payment of final compensation is made. If you are unable to obtain one, you must submit a notice explaining why you are unable to obtain one or the date you anticipate submitting one. If the original medical report was not that of the treating practitioner, a treating practitioner’s report is necessary if temporary disability exceeds 3 weeks or if permanent disability has resulted. A copy of information contained in the final WKC-13 report and the final practitioner’s report must be sent to the employee. INSTRUCTIONS ON HOW TO COMPLETE THIS FORM: Items 1 thru 11. Fill in all blanks completely. Item 12. Fill in the mailing address of the office or adjusting company that makes the payments. All correspondence regarding this injury will be mailed to the insurer’s designated claims handling address. Items 13 thru 16. Fill in all blanks completely. If salary/wage is continued, check the box and include the weekly amount of salary in Item 15. If first payment covered temporary partial disability, check the box in Item 13. Include a WKC-13A for TPD if TTD rate is less than minimum. Item 17. If the first payment was made more than 14 days after the date of injury or the day the employee left work prior to the first day for which WC is paid, give reason for the delay in payment. Item 18. If payments are suspended for any reason other than return to work, state the reason. Explain unusual circumstances under “other remarks.” If benefits are denied, be sure to include a copy of the denial letter to the worker. Enter the date the final medical report is anticipated if one is required under DWD 80.02(2)(e)4 and is not attached or previously sent. A final treating practitioner’s report is due if there is any permanent disability or more than 3 weeks of temporary disability paid, including TPD or salary/wage continued. Item 19. Check the appropriate box for the type of temporary total disability paid using sections 1-4 or attach another form if there are more payment periods of temporary total (TTD) or temporary partial disability (TPD) paid. If permanent partial disability (PPD), salary continued, vocational rehabilitation or any other types of payments were made, indicate the payment type under “other”. Items 20 and 21. Enter the last day of work and the return to work or end of healing dates. Do not enter the return to work or end of healing date unless the type of compensation paid for that period has been suspended. Item 22. Enter the number of holidays paid by the employer and not paid WC for each period of disability. Item 23. Enter the number of whole weeks and days paid TTD or, if TPD, the number of days for which TPD was paid. Any part of one day paid is considered a whole day for TPD purposes. Items 24 and 25. Enter the rates and compensation paid that applies to the weeks or days in items 20-23. Item 26. Enter the cumulative total of compensation paid for that line, items 19-25. Item 27. Enter the number of weeks due, the permanent partial disability rate, and total compensation due for the disability. (Follow Sec.102.52, 102.53, and 102.55 where applicable.) Attach supporting medical information if it was not previously submitted. Item 28. Enter the date of the final payment of temporary compensation if the claimant has returned to work or has been released for work and all temporary compensation due has been paid. Enter the date of final payment of PPD or other type of payment. Item 29. Check the appropriate box if all temporary compensation has been paid and a date in item 28 has been entered. Sample of Items 19 – 26 Payment Period 19. Type of Payment 22. Last Day of Work 23. Date of Return to Work or End of Healing (Do not enter if TTD or TPD continues to be paid) 22. No. of Employer Paid Holidays 23. No. of Weeks and/or Days Paid 24. Rate 26. Amount of Comp. Paid 26. Accumulated Total Amount Paid  TTD  TPD  Other: 2/1/99 6/6//99 3 17+2 days $ 538.00 $ 9,325.32 $ 9,325.32  TTD  TPD  Other: 6/6/99 8/8/99 0 9 $ 220.00 $ 1,980.00 $ 11,305.32  TTD  TPD  Other: Salary Cont’d 8/8/99 9/6/99 0 4 $ 538.00 $ 2,152.00 $ 13,457.32  TTD  TPD  Other: Vocational Rehab 9/6/99 12/21/99 0 15 $ 538.00 $ 8,070.00 $ 21,527.32