Supplemental Payments Reimbursement Request
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Supplemental Payments Reimbursement Request Form. This is a Wisconsin form and can be use in Workers Comp.
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Tags: Supplemental Payments Reimbursement Request, WKC-140, Wisconsin Workers Comp,
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-mail: DWDDWC@dwd.wisconsin.gov
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 Workforce Development, Worker’s Compensation Division
Request is made for reimbursement of supplemental benefits paid during the preceding calendar year under the provisions of
s.102.44(1), Wisconsin Statutes, in the following case and in the amount indicated.
WC Claim Number
Employee Name
Employee Social Security Number
Employer Name
Injury Date (MM/dd/yyyy)
Insurance Company Name
u
Weekly
Supplemental Rate
Begin
Date
(MM/dd/yyyy)
Number
of Weeks
and Days
End
Date
(MM/dd/yyyy)
Amount of
Reimbursement
Requested
Weeks:
Days:
Weeks:
Days:
Weeks:
Days:
Weeks:
Days:
Total: $0.00
I certify the above amount requested for reimbursement is true and correct and was paid during the preceding calendar year.
Name of Carrier or Exempt Employer to Whom Check Should be Mailed
Mailing Address (Number, Street, City, State, Zip Code)
Signed by
Title
FEIN Number
Date Signed (MM/dd/yyyy)
Telephone Number
(
)
-
Ext.
WKC-140 (R. 03/2009)
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