Supplemental Payments Reimbursement Request for Workers' Compensation - Wisconsin 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the injured employee's name in the designated field. Ensure that you list each employee alphabetically for clarity.
3. Next, input the employer's name and the date of injury. This information is crucial for processing your request accurately.
4. Fill in the weekly supplemental rate and specify the time period covered, including the number of weeks and days. This section helps determine the total reimbursement amount.
5. In the 'Amount of Reimbursement Requested' field, calculate and enter the total amount you are requesting based on previous entries.
6. Complete the certification statement by signing your name, providing your title, FEIN number, and telephone number. Make sure all details are accurate before submission.
7. Finally, review all entered information for accuracy and completeness before submitting your form as instructed at the top of this document.

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