WKC-16-B-E - Wisconsin Department of Workforce Development 2025

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The document is a practitioner's report form for worker's compensation claims in Wisconsin, detailing the necessary information regarding an employee's accident or industrial disease. It includes sections for personal and employer details, descriptions of the incident, medical evaluations, disability assessments, and practitioner certification. The report serves as a formal record to support claims related to workplace injuries or conditions.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the WC Claim Number and Employee Social Security Number. Note that providing your SSN is voluntary but may prevent processing delays.
Fill in the Employee Name and Address, followed by the Employer Name and Address. Ensure all details are accurate for proper identification.
Describe the traumatic event or work exposure in detail. You can attach a copy of medical history if it contains this information.
Provide a complete description of the physical or mental disability along with the diagnosis, again attaching relevant medical notes if necessary.
Indicate whether you treated the patient and specify treatment dates. Include the date of last examination and when disability from work began.
Answer questions regarding return to work capabilities, including any temporary or permanent limitations.
Complete sections on prognosis, further treatment expectations, and prior disabilities before certifying your report with your signature and date.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How much is the permanent partial disability settlement in Wisconsin?

If an employee dies due to a work-related injury or illness, workers compensation death benefits, also called workers comp survivor benefits, can help provide financial support for the family or dependents of the deceased. Of course this is a facet of business insurance that no one ever hopes to experience.

What is the death benefit payout?

In addition to death benefits, the workers comp insurance company must pay the reasonable burial expenses for the deceased employee, up to a maximum of $10,000 for injuries that happened after 2012. (Cal. Labor Code 4701(a) (2023).) Otherwise the amount is $5,000.

What is the death benefit for workers comp in Wisconsin?

What is the Coming and Going Rule? In order for an accident to be covered by workers compensation in Wisconsin, it must occur in the course of employment. This means that the accident must occur at a time, place, and under the right circumstances to be considered in the course of employment.

What does the Wisconsin Department of Workforce Development do?

In certain circumstances, death benefits may be due to the deceased workers dependents. The maximum amount of the death benefit is four times the average annual earnings of the worker. The questions regarding who will get the benefits and how much the benefits will be can be complicated.

What is the maximum benefit for funeral and burial expenses under workers compensation?

Under the law, the maximum weekly Permanent Partial Disability (PPD) benefit rate increases from $362 to $415 for injuries occurring on or after April 10, 2022, and will increase further to $430 for injuries occurring on or after January 1, 2023.