Wisconsin Department of Workforce Development

Worker's Compensation Division  > Standard Letters  

August 19, 1998

SAMPLE INSURANCE CO
C/O SAMPLE INSURANCE CO
%W C DIVISION
204 E WASHINGTON #161
MADISON WI 53720

WC CLAIM NO: 9999-999999
INJURY DATE: 03/30/86
EMPLOYE: SIMPLE, SAMPLE
EMPLOYER: SIMPLE SAMPLE EMPLOYER
INSURER NO:

We received information which indicates that the average weekly wage you used for computing the TTD rate may be incorrect. In order for us to verify the correct average weekly wage, please send us a list of the number of hours that the employe worked, week-by-week, during each of the 13 weeks prior to the injury. Do not include the week of injury.

Thank you for your help in assuring correct compensation payments.

Failure to respond to this request within 30 days may result in sanctions by the Worker’s Compensation Division under ss. 102.28(2)(c) or 102.31(3), Wis. Stats., or by the Office of the Commissioner of Insurance, under s. 601.64,Wis. Stats., or both.

 

Wage Analyst
(608)-266-3264

WC45L

(R. 3/16/98)