IMPORTANT NOTICE: WORK RELATED INJURIES MUST BE REPORTED IMMEDIATELY

The state which your Workers Compensation policy covers requires that injuries and illnesses to your employees be reported in a timely manner. It is your responsibility to report any employee injury directly to your insurance carrier.

In the State of Wisconsin, an Employer’s First Report of Injury or Disease claim form (WKC-12-E) should be filed within ONE DAY of the date of injury where it is suspected that your employee will lose time from work.

Employer's First Report of Injury or Disease Forms:

WKC-12-E Form, Editable Word Document

WKC-12 Form, PDF Document

If the injury results in the death of an employee your claim must be reported to both

1. your insurance company and
2. the WCD within 24 HOURS of the injury.

Other on-the-job injuries should be reported promptly. Failure to do so can result in the imposition of a fine by the State of Wisconsin—these penalties can be severe and are not covered by your Workers Compensation policy. For more information, visit the WCD website shown below.

If a work related injury occurs in any other state, you must refer to your insurance policy or call our office to learn how claims should be reported. Generally states require a claim to be reported within ONE DAY of the date of the injury for lost time, within 24 HOURS if the injury results in death of the employee or within THREE DAYS for other work related accidents or illnesses where medical attention is sought. You must refer to your policy for each state’s specific requirements.

Early reporting allows your insurance carrier time to investigate the injury and begin any case management that your employee may need. It also provides ample time to pay medical bills and lost wages on behalf of your employee.

You may contact the Worker’s Compensation Division of the DWD at:

Wisconsin Department of Workforce Development, Worker’s Compensation Division

201 E Washington Avenue, Room C100, PO Box 7901

Madison, Wisconsin 53707-7901

Phone 608-266-1340/Fax 608-267-0394

www.dwd.state.wi.us/wc

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