Wkc 12 E Form PDF Details

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QuestionAnswer
Form NameWkc 12 E Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswisconsin disease dwd, wi wkc workforce development, wi wkc dwd workforce, wi employers injury dwd

Form Preview Example

EMPLOYER’S FIRST REPORT OF INJURY OR DISEASE

Fatal Injuries: Employers subject to ch.102, Wis. Stats., must report injuries resulting in death to the Department and to their insurance carrier, if insured, within one day after the death of the employee. Non-Fatal Injuries: If the injury or occupational illness results in disability beyond the three-day waiting period, the employer, if insured, must notify its insurance carrier within 7 days after the injury or beginning of disability. Medical-only claims are to be reported to the insurance carrier only, not the Department.

Electronic Reporting Requirement: All work-related injuries and illnesses resulting in compensable lost time, with the exception of fatalities, must be reported electronically to the Department via EDI or Internet by the insurance carrier or self-insured employer within 14 days of the date of injury or beginning of disability. Employer may fax claims for fatal injuries to (608) 267-0394.

Department of Workforce Development

Worker’s Compensation Division

201 E. Washington Ave., Rm. C100 P.O. Box 7901

Madison, WI 53707

Imaging Server Fax: (608) 260-2503

Telephone: (608) 266-1340 http://www.dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov

*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].

(Please read the instructions on page 2 for completing this form)

EMPLOYER EMPLOYEE

WAGE INFORMATION

INJURY INFORMATION

Employee Name (First, Middle, Last)

 

 

 

 

 

 

 

Social Security Number*

 

Sex

 

Employee Home Telephone No.

 

 

 

 

 

 

 

 

 

 

-

-

 

 

 

 

M

F

(

)

-

Employee Street Address

 

 

 

 

 

 

City

 

 

 

 

State

 

 

Zip Code

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birthdate

 

Date of Hire

 

 

 

County and State Where Accident or Exposure Occurred?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

WI Unemployment Ins. Acct No.

Self-Insured?

Nature of Business (Specific Product)

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

Employer Mailing Address

 

 

 

 

 

 

City

 

 

 

 

State

 

Zip Code

 

 

Employer FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

-

Name of Worker’s Compensation Insurance Co. or Self-

Insured Employer

 

 

 

 

 

 

 

 

 

Insurer FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

Name and Address of Third Party Administrator (TPA) Used by the Insurance Company or Self-Insured Employer

 

 

TPA FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

Wage at Time of Injury

Specify per hr., wk., mo., yr., etc.

In Addition to Wages,

Meals

No. of Meals/wk.

$

 

Per:

 

 

 

 

 

 

Check Box(es) if

Room

No. of Days/wk

 

 

 

 

 

 

 

 

Employee Received:

Tips

Avg. Weekly Amt. $

 

 

 

 

 

 

 

 

Is Worker Paid for Overtime?

Yes

No If Yes, After How Many Hours of Work Per Week?

 

 

 

For the 52 Week Period Prior to the Week the Injury Occurred, Report Below the Number of Weeks Worked in the Same Kind of Work, and the Total Wages, Salary, Commission and Bonus or Premium Earned for Such Weeks.

No. of Weeks:

 

Gross Amount Excluding Tips: $

 

 

 

If Piece-Work, No. of Hrs. Excluding Overtime:

 

 

 

 

 

 

 

 

 

 

 

Start Time

 

 

 

Hours Per Day

 

Hours Per Week

 

Days Per Week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee’s Usual Work Schedule When Injured:

 

:

AM

PM

 

 

 

 

 

 

 

 

 

Employer’s Usual Full-Time Schedule for This

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Work at Time of Employee’s Injury:

 

 

 

 

 

 

 

 

 

 

 

 

 

Part-Time

 

 

 

Are there Other Part-Time Workers Doing the Same Work

Number of Full-Time Employees Doing The

Employment

 

 

With the Same Schedule?

 

 

 

 

 

Same Type Of Work:

 

 

Information:

 

 

 

Yes

 

 

No

If yes, how many?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injury Date

 

Time of Injury

 

 

 

Last Day Worked

Date Employer Notified

 

 

Date Returned to Work

 

 

 

 

:

 

AM

: PM

 

 

 

 

 

 

 

 

 

Estimated Date of Return

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did Injury Cause Death?

 

Date of Death

Was This a Lost Time or Other

Did Injury Occur Because of:

 

 

Yes

No

 

 

 

 

 

 

 

Compensable Injury?

 

 

Substance

Failure to Use

 

Failure to

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Abuse

Safety Devices

 

Obey Rules

Was Employee Treated in an Emergency Room? Yes No Was Employee Hospitalized Overnight as an In-Patient? Yes No Name and Address of Treating Practitioner and Hospital:

Case Number from the OSHA Log:

Injury Description - Describe Activities of Employee When Injury or Illness Occurred and What Tools, Machinery, Objects, Chemicals, Etc. Were Involved.

What Happened to Cause This Injury or Illness? (Describe How The Injury Occurred)

What Was The Injury or Illness? (State the Part of Body Affected and How It Was Affected)

Report Prepared By

Work Phone Number

Position

Date Signed

 

( )

-

 

 

 

 

 

WKC-12-E (R. 06/2017)

SEND REPORT IMMEDIATELY - DO NOT WAIT FOR MEDICAL REPORT

 

EMPLOYER AND INSURANCE CARRIER INSTRUCTIONS

The employer must complete all relevant sections on this form and submit it to the employer’s worker’s compensation insurance carrier or third party claim administrator within seven (7) days after the date of a

work-related injury which causes permanent or temporary disability resulting in compensation for lost time. The employer’s insurance carrier or the third-party claim’s administrator may request that this form also be

used to immediately report any injury requiring medical treatment, even though it does not involve lost work time.

For any work injury resulting in a fatality, the employer must also submit this form directly to the Department of Workforce Development within 24 hours of the fatality.

An employer exempt from the duty to insure under s. 102.28, Wis. Stats., and an insurance carrier administering claims for an insured employer are required to submit this form to the Department of Workforce Development within 14 days of the date of work injury.

MANDATORY INFORMATION

In order to accurately administer claims, each of the following sections of this form must be completed. The First Report of Injury will be returned to the sender if the mandatory information is not provided.

Employee Section: Provide all requested information to identify the injured employee. If an employee has multiple dates of employment, the “Date of Hire” is the date the employee was hired for the job on which he or

she was injured.

Employer Section: Provide all requested information to identify the injured worker’s employer at the time of

injury. Provide the name and Federal Employer Identification Number (FEIN) for the insurance carrier or self- insured employer responsible for the worker’s compensation expenses for this injury. Also identify the third

party claim administrator, if one is used for this claim.

Wage Information Section: Provide the information requested regarding the injured employee’s wage and hours worked for the job being performed at the time of injury.

Injury Information Section: Provide information regarding the date and time of injury. Provide a detailed description of the injury, including part of the body injured, the specific nature of the injury (i.e., fracture, strain, concussion, burn, etc.) and the use of any objects or tools (i.e., saw, ladder, vehicle, etc.) that may have caused the injury. Provide the name of the person preparing this report and the telephone number at which they may be reached, if additional information is needed. This form was designed to include information required by OSHA on form 301. If this section is completed and retained, the employer will not have to complete the OSHA 301 form.

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