Worker's Compensation division - Wisconsin Department of ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the WC Claim Number at the top of the form. This is essential for tracking your case.
3. Fill in the Employee Name and Birth Date fields accurately to ensure proper identification.
4. Provide the Employee Social Security Number if comfortable, noting that it is voluntary but may expedite processing.
5. Complete the Employee Mailing Address section with current details, including street, city, state, and zip code.
6. Indicate the Date of Alleged Injury and provide information about the Employer Name and Insurance Company Name along with their addresses.
7. Specify whether it is disputed or undisputed that the employee was employed by the respondent employer.
8. Enter details regarding Employee Earned Weekly Wage and Compensation Previously Paid in their respective fields.
9. Review all entries for accuracy before signing. Ensure all parties involved sign where indicated.

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