Get Wi Wkc-16-b 2014-2025

The WI WKC-16-B is a vital form used in Wisconsin for reporting accidents or industrial diseases on behalf of an employee. This guide will provide you with clear, step-by-step instructions on how to complete this form effectively and accurately in an online format.

Follow the steps to fill out the WI WKC-16-B online successfully.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Begin by entering the WC claim number, the employee's name, Social Security Number, and their address in the first section. Remember, providing the Social Security Number is voluntary.
3. In the second section, provide the employer's name and the date of the traumatic event, followed by the worker’s compensation insurance carrier and employer address.
4. In the next section, detail the accidental event or work exposure related to the patient’s condition. If you have a copy of relevant medical history or notes, you may attach it for completeness.
5. Describe the physical or mental disability along with the diagnosis thoroughly. Attach any medical history if necessary.
6. Indicate whether you treated the patient and specify the treatment dates if applicable.
7. Enter the date of the last examination or evaluation in the designated field.
8. Record the start date of the disability from work as well as the anticipated date when the employee can return to a limited type of work, including any temporary limitations.
9. Specify the date when the employee can return to full-time work, mentioning any permanent limitations.
10. State whether it is probable that the event described caused the disability.
11. If workplace exposure contributed to the condition, indicate if it was the sole cause or at least a material factor.
12. Answer whether the event aggravated a preexisting condition.
13. Report if the accident resulted in any permanent disability and estimate the percentage related to the injury.
14. Describe the elements that constitute permanent disability, including any relevant details about motion limitations or other symptoms.
15. Provide the prognosis of the disability and any expected need for further treatment.
16. Indicate if the employee had any permanent disability prior to this incident and provide details if applicable.
17. Complete the practitioner information, including your typed or printed name and address.
18. Certify the information by signing and dating the form. Ensure your contact number and college affiliation are included.
19. Once all fields are completed, save your changes, then download, print, or share the form as needed.

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