Fill and Sign the Wkc 140 Supplemental Payments Reimbursement Request This is a Request by an Insurance Carrier or Self Insured Employer for Form

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 W orkforce Development, W orker’s Compensation Division Request is made for reimbursement of supplemental benefits paid during the preceding calendar year under th e provisions of s.102.44(1), W isconsin Statutes, in the fo llowing case and in the amount indicated. WC Claim Number Employee Name Employe e Social Security Number * Employer Name Injury Date (MM/dd/yyyy ) Insurance Company Name Original Reimburse ment Request Adjusted Reimbursement Request Weekly Supplemental Rate Begin Date (MM/dd/yyyy ) End Date (MM/dd/yyyy ) Number of Weeks and Days Calendar Year in Which the Payments Were Made Amount of Reimbursement Requested W eeks: Days: Year: W eeks: Days: Year: W eeks: Days: Year: W eeks: Days: Year: Total: $0.00 I certify the above amount requested for reimbursem ent is true and correct. I also certify that the reimbursement requested is for supplemental benefit payments paid during the preceding calendar year. Name of Carrier or Exempt Employer to Whom Check Should be Mailed Mailing Address (N umber, Street, City, State, Zip Code ) Signed by Title Date Signed (MM/dd/yyyy ) FEIN Number Telephone Number ( ) - Ext. WKC -140 (R. 06/20 17) 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-ma il: DWDDWC@dwd.wisconsin.gov