Form WC00 "Replacement of Prescription Eyeglasses" - Kansas

What Is Form WC00?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2010;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form WC00 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form WC00 "Replacement of Prescription Eyeglasses" - Kansas

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R
P
E
EPLACEMENT OF
RESCRIPTION
YEGLASSES
An application for workers compensation benefits has been submitted by your employer to the State Self
Insurance Fund (SSIF). This form pertains only to your prescription eyeglasses.
Name:
Accident Date:
Home Address:
Employed by:
Supervisor’s Name:
Name and address where services will be provided:
Before this incident, when was your last vision exam and by whom?
Check the portion below that pertains to your glasses:
Broken
Bent
Repaired
Replaced
F
RAMES
Metal
Plastic
Pitted
Broken
Scratched
Replaced
L
ENS
Right
Left
L
ENS
Glass
Photo-Gray
Plastic
Tint
Bifocal
Tri-Focal
No-lines
Name and address of the provider where you purchased your new glasses:
Did you have your eyes examined? If so, by whom:
List any special features (scratch-resistant finish, oversized lenses, etc):
R
:
ETURN COMPLETED FORM TO
State Self Insurance Fund
Rm. 900-N, Landon State Office Bldg.
900 SW Jackson Street
Topeka, Kansas 66612
C
:
ONTACT US BY
785-296-2364 - P
HONE
785-296-6995 - FAX
Form WC-00
Rev.: 04/10
R
P
E
EPLACEMENT OF
RESCRIPTION
YEGLASSES
An application for workers compensation benefits has been submitted by your employer to the State Self
Insurance Fund (SSIF). This form pertains only to your prescription eyeglasses.
Name:
Accident Date:
Home Address:
Employed by:
Supervisor’s Name:
Name and address where services will be provided:
Before this incident, when was your last vision exam and by whom?
Check the portion below that pertains to your glasses:
Broken
Bent
Repaired
Replaced
F
RAMES
Metal
Plastic
Pitted
Broken
Scratched
Replaced
L
ENS
Right
Left
L
ENS
Glass
Photo-Gray
Plastic
Tint
Bifocal
Tri-Focal
No-lines
Name and address of the provider where you purchased your new glasses:
Did you have your eyes examined? If so, by whom:
List any special features (scratch-resistant finish, oversized lenses, etc):
R
:
ETURN COMPLETED FORM TO
State Self Insurance Fund
Rm. 900-N, Landon State Office Bldg.
900 SW Jackson Street
Topeka, Kansas 66612
C
:
ONTACT US BY
785-296-2364 - P
HONE
785-296-6995 - FAX
Form WC-00
Rev.: 04/10