Wisconsin Supplementary Report on Accidents and Industrial Diseases -- Supplemental report to be filed by the insurer or self-insured employer when payments are started, stopped, suspended or changed. This version is protected from modification and enabled for form

• Category: Wisconsin Workers Compensation - Official
• State: Wisconsin
• Control #: WI-SKU-2379
• Format: PDF

Description

Supplementary Report on Accidents and Industrial Diseases -- Supplemental report to be filed by the insurer or self-insured employer when payments are started, stopped, suspended or changed. This version is protected from modification and enabled for form The Wisconsin Supplementary Report on Accidents and Industrial Diseases is a supplemental report to be filed by the insurer or self-insured employer when payments are started, stopped, suspended or changed for an injured employee due to an accident or industrial disease. The report must include basic information about the injured employee, such as name, date of birth, address, and the nature of the injury, as well as details of the payment being made. It must also include information about any previous accidents or industrial diseases that the employee has suffered from, as well as any other relevant medical or employment history. The Wisconsin Supplementary Report is available in two forms, depending on the type of payment being made. The first form is used for payments made through a Workers' Compensation Claims Administrator, while the second form is for payments made directly by the insurer or self-insured employer. The form also includes information about the medical provider, the amount of the payment, and the date it was made. The report must be signed and dated by the responsible party and must be sent to the Wisconsin Department of Workforce Development. It must be filed within 30 days of the payment being made or the change being made to the payment. The report can be submitted electronically or by mail.

The Wisconsin Supplementary Report on Accidents and Industrial Diseases is a supplemental report to be filed by the insurer or self-insured employer when payments are started, stopped, suspended or changed for an injured employee due to an accident or industrial disease. The report must include basic information about the injured employee, such as name, date of birth, address, and the nature of the injury, as well as details of the payment being made. It must also include information about any previous accidents or industrial diseases that the employee has suffered from, as well as any other relevant medical or employment history. The Wisconsin Supplementary Report is available in two forms, depending on the type of payment being made. The first form is used for payments made through a Workers' Compensation Claims Administrator, while the second form is for payments made directly by the insurer or self-insured employer. The form also includes information about the medical provider, the amount of the payment, and the date it was made. The report must be signed and dated by the responsible party and must be sent to the Wisconsin Department of Workforce Development. It must be filed within 30 days of the payment being made or the change being made to the payment. The report can be submitted electronically or by mail.