Get the free K-WC 97 (Rev. 5-99). K-WC 97 (Rev. 5-99)

For Official Use Only KANSAS DEPARTMENT OF HUMAN RESOURCES DIVISION OF WORKERS COMPENSATION 800 S.W. Jackson Street, Suite 600, Topeka, Kansas 66612-1227 Phone: (785) 296-3441 Fax: (785) 291-3430

How to fill out k-wc 97 rev 5-99

How to fill out k-wc 97 rev 5-99:

1. Start by obtaining a copy of the k-wc 97 rev 5-99 form. This form is typically used for reporting work-related injuries and illnesses in the state of Wisconsin.
2. Begin by filling out the personal information section at the top of the form. This includes providing the name of the injured or ill worker, their social security number, and their date of birth.
3. Next, provide the contact information for the employer, including the company name, address, and phone number.
4. Proceed to the "Injured/Employer Information" section. Here, you will need to provide details about the injury or illness, including the date it occurred, the time it happened, and a brief description of what took place. If the injury resulted in death, this section should also include the date and time of death.
5. In the "Nature of Injury/Illness" section, you will need to provide a detailed description of the injury or illness. This includes specifying the body part affected, the nature of the injury (such as a sprain or fracture), and the cause.
6. The "Lost Time Information" section should be completed if the worker missed work due to the injury or illness. Specify the first day of lost work, the ending date if known, and the number of days lost.
7. If the injured or ill worker received any medical treatment, mark the appropriate box and provide the name and address of the healthcare provider.
8. In the "Wage Information" section, enter the worker's average weekly wage, which is typically determined by considering their earnings over the previous 52 weeks.
9. Finally, the form must be signed and dated by the employer or their representative. Make sure all the required fields are filled out accurately before submitting the form to the appropriate authority.

Who needs k-wc 97 rev 5-99:

1. Employers who have employees working in the state of Wisconsin and who experience work-related injuries or illnesses need k-wc 97 rev 5-99. This form is required for reporting such incidents to the Workers' Compensation Division.
2. Injured or ill workers who are seeking workers' compensation benefits also need k-wc 97 rev 5-99. This form helps document their injuries or illnesses and serves as a crucial part of the claim process.
3. Healthcare providers who have treated workers for work-related injuries or illnesses in Wisconsin may also use k-wc 97 rev 5-99 to document the medical treatment provided, which is essential for determining the extent of the injury and the appropriate compensation.

For pdfFiller’s FAQs

What is k-wc 97 rev 5-99?

k-wc 97 rev 5-99 is a form used for reporting workers' compensation insurance coverage information.

Who is required to file k-wc 97 rev 5-99?

Employers with workers' compensation insurance coverage are required to file k-wc 97 rev 5-99.

How to fill out k-wc 97 rev 5-99?

You can fill out k-wc 97 rev 5-99 by providing information about your workers' compensation insurance coverage and employer details.

What is the purpose of k-wc 97 rev 5-99?

The purpose of k-wc 97 rev 5-99 is to report workers' compensation insurance coverage information to the appropriate authorities.

What information must be reported on k-wc 97 rev 5-99?

Information such as the policy number, effective date, insurance carrier, and employer details must be reported on k-wc 97 rev 5-99.

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