Get Wkc-177 - Department Of Workforce Development - Wisconsin.gov - Dwd Wisconsin

Filling out the WKC-177 form is an important step in the worker's compensation process. This guide will help you complete this document accurately and efficiently, ensuring that all necessary information is provided.

Follow the steps to complete the WKC-177 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editing tool.
2. Begin by providing your WC Claim Number, which is essential for tracking your application.
3. Next, fill in the employee's name, social security number (SSN), and mailing address, ensuring accuracy to prevent delays. Remember, providing your SSN is voluntary.
4. Input the employee's birth date and the date of the alleged injury, as these dates are critical for processing your claim.
5. Provide the employer's name and their mailing address, which helps in identifying the party responsible for the workplace.
6. Fill out the insurance company name and their address to ensure that the correct insurance provider is notified about the claim.
7. Indicate the employee’s average weekly wage at the time of the injury, which is necessary for calculating compensation.
8. Document any temporary disability periods, specifying dates to track duration of absence due to the injury.
9. If applicable, state the percentage of permanent disability conceded and the number of weeks, alongside any compensation amounts paid and attorney fees.
10. List all medical expenses to be paid. Be detailed, as this lays out the costs incurred due to the injury.
11. Once all sections are complete, review for accuracy and completeness before proceeding to sign.
12. Sign the form as the employee and ensure the insurance company representative or self-insured employer also signs before submission.
13. Attach all relevant medical reports as required.
14. Finally, save your changes, download the completed form, and share or print it as necessary.

Complete your WKC-177 form online today to ensure prompt processing of your worker's compensation claim.