Employer's First Report of Injury or Disease

Document Number:  WKC-12-E

Description:  This form is for the employer to report every work-related injury to its insurance company.  If an employee is out more than 3 days due to a work-related injury, or there is PPD, a copy is to be sent to the Worker's Compensation Division by the employer's worker's compensation insurance carrier, not by the employer (unless the claim is a fatality).  Except for fatalities, the information on this form must be sent electronically by the employer's worker's compensation carrier to the WC Division.

Comments:  This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word).  If you do not have Microsoft Word, we are providing a .pdf (WKC-12) which you can print and complete by hand.

Content Contact:  Kathy Froehlich

Document Attachments:

WKC-12-E (Electronic Version - Word/96 KB)

WKC-12 (Print Version - pdf/83 KB)

*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.

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