State Self Insurance Fund Forms


Important Information for Injured Employees
K-WC 27 - (Rev. 06-12) English Version
K-WC-270 - (Rev. 06-12) Spanish Version
Applies only to injuries on or after May 15, 2011 and before April 25, 2013
K-WC 27-A - (Rev. 04-13) English Version
K-WC 270-A - (Rev. 04-13) Spanish Version
Applies only to injuries on or after April 25, 2013
FORMS NOTICES

Employer's Report of Accident

K-WC40 - Rev 04/13 - Injuries ON OR AFTER May 15, 2011 and BEFORE April 25, 2013
Injured Employee's Report of Accident K-WC40-A - Rev 04/13 - Injuries ON OR AFTER April 25, 2013

Mileage Reimbursement Form

 
Prescription Eyeglass Replacement Form
Eyeglass Repair or Replacement Guidelines

First Fill Letter

 
   

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