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MCIM Claim Forms - Wisconsin

First Report of Injury 
​Informe Basico de Lesion Del Empleador
   
NOTE: Adobe Acrobat Approval, Standard, or Professional version 5 or newer is required for submitting this form by email.
Please report injuries to mcim as soon as possible.

Wage Statement  
Declaración del Salario
This form is necessary in all lost time cases where wages will be paid to the injured worker. The Workers' Compensation Act requires that we have 52 weeks of prior wage information whenever possible to determine the rate at which they will be paid.

Mileage Reimbursement 
Petición de Reembolso del Kilometraje

This form is included for the worker’s convenience in requesting reimbursement for mileage incurred traveling to medical appointments in connection with the injury. Injured Worker’s can submit thoroughly completed forms to their examiner.

Medical Authorization    
Authorization to obtain medical information.

Employee Questionnaire    
Cuestionario al Empleado
Initial Form to be completed by the injured worker.

Witness Statement
Form to be completed by a witness to the accident.

Fraud Investigation Notice 

Accident Investigation Report     

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  • Home
  • About MCIM
    • Products & Services
    • Leadership
    • News
    • Careers
  • Claims
    • Report an Injury
    • Return to Work Program
    • The Value of Early Reporting
    • Florida Claims Forms
    • Georgia Claims Forms
    • Illinois Claims Forms
    • Indiana Claims Forms
    • Michigan Claims Forms
    • Wisconsin Claims Forms
  • Loss Prevention
    • Safety Inspections
    • Safety Resources
    • Safety Training Videos
    • Safety Training Programs
  • Bill Pay
  • Agencies
  • Contact Us
  • My MCIM
    • Newsletters