Supplemental Payments Reimbursement Request

Document Number:  WKC-140-E

Description:  This is a request by an Insurance Carrier or Self-Insured Employer for reimbursement of supplemental benefits.

Comments:  This form is an electronic Microsoft Word template that can filled out on your computer (if you have Microsoft Word). If you do not have Microsoft Word we are providing a PDF (WKC-140) which you can print and complete by hand.

Content Contact:  Kathy Froehlich

Document Attachments:

WKC-140-E (Electronic Version - Word/73 KB)

WKC-140 (Print Version - pdf/11 KB)

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

*** Should you require the necessary software to view the above attachment, please go to the DWD Viewers Download Page.  Links to each specific vendor's site have been provided for you.  Thank you.