Listing of Worker's Compensation Standard Letters

 

AU03 (PDF) We are making an annual follow-up for this permanent total injury. Please answer the questions below and return this form or a photocopy.
AU04 (PDF) Annual follow-up for a fatal injury. This form needs to be completed and returned or a photocopy of the form returned.
BIP1ST (PDF) Self-Insured Employer-we did not receive an answer to our request for information required by the first supplemental report(WKC-13)
BIP77A (PDF) Self-Insured Employer-we did no t receive an answer to our balance due letter.
BIPFNL (PDF) Self-Insured Employer-we did not receive an answer to our request for an updated or final Supplemental Report (WKC-13)
BIPINV (PDF) Self-Insured Employer-we did not receive an answer to our request for information on the results of your investigation of the claim.
BIPMED (PDF) Self-Insured Employer-we did not receive an answer to our request for an updated or final medical report from the treating doctor.
BIPWGE (PDF) Self-Insured Employer-we did not receive an answer to our request for wage information.
GL05 (PDF) We received a Supplementary Report on Accidents and Industrial Diseases (WKC-13) for this temporary partial disability claim, but you failed to include a copy of your calculations worksheet. Please complete form WKC-7359, Temporary Partial Disability, and return it with an updated WKC-13
GL06 (PDF) We received a Supplementary Report, WKC-13, which indicates you are investigating this claim. Request for information regarding status of investigation of claim.
GL10 Letter to claimant saying we need a final medical report from the treating doctor.
GL24 Request for final medical from treating practitioner or re-estimate the date by which you expect to submit one due to one of the following: 1) received not final medical report, 2) received final medical not from treating practitioner, 3) the date you estimated to submit a final report as passed.
GL45A (PDF) We were advised that a completed Wage Report, WKC-13-A, would be submitted, but have not received it.
GL58 You have advised us that the reason for your delay in making the first payment is that you were conducting an investigation of this claim. It is the Department’s position that an investigation of more than six weeks is unreasonable. Therefore, we are assessing you with the 10 percent delay penalty in accordance with Sec. 102.22 of the Worker’s Compensation Act.
GL70 (PDF) Hearing loss claim and we need a copy of the audiograms.
GL71 (PDF) Received a medical report assessing permanent disability as a result of this injury. The payment information submitted reflects the injured employee lost no time from work, the medical report indicates the employee did lose time from work either as a result of surgery or within the three-day waiting period.
GL102 (PDF) Requesting the Employee's Attorney's name and address.
FWC12 (PDF) Forfeiture and failure to timely file the First Report of Injury, WKC-12.
FWC24 (PDF) Forfeiture and request for final medical from treating practitioner or re-estimate the date by which you expect to submit one due to one of the following: 1) received not final medical report, 2) received final medical not from treating practitioner, 3) the date you estimated to submit a final report has passed.
FWC45A (PDF) Forfeiture and second request for wage information required by Form WKC-13-A
FWC45B (PDF) Forfeiture and second request for wage information (gross earnings and weeks worked).
FWC45D (PDF) Forfeiture and second request for wage information (part-time work information).
FWC45H (PDF) Forfeiture and second request for wage information (gross earnings and part-time work information).
FWC45M (PDF) Forfeiture and second request for wage information (gross earnings & overtime).
FWC45P (PDF) Forfeiture and second request for wage information (52-week gross detail).
FWC86A (PDF) Forfeiture and second request for an updated or final Supplemental Report, WKC-13.
FWC86D (PDF) Forfeiture and Second request for final medical report from treating practitioner with the WKC-13.
FWC86G (PDF) Forfeiture and Second request for overdue Supplementary WKC-13.
FWC86K (PDF) Forfeiture and Second Request for information regarding the required Supplementary WKC-13 required when a compromise or stipulation is received by the division.
OCI24R (PDF) We did not receive an answer to our request for an updated or final medical report from the treating doctor.  (Referral letter to the Office of the Commissioner of Insurance.)
OCI45A We did not receive an answer to our request request for wage information required by Form WKC-13-A. (Referral letter to the Office of the Commissioner of Insurance.)
OCI45B We did not receive an answer to our request request for wage information (gross earnings and weeks worked). (Referral letter to the Office of the Commissioner of Insurance.)
OCI45D We did not receive an answer to our request request for wage information (part-time work information). (Referral letter to the Office of the Commissioner of Insurance.)
OCI45H We did not receive an answer to our request request for wage information (gross earnings and part-time work information). (Referral letter to the Office of the Commissioner of Insurance.)
OCI45M We did not receive an answer to our request request for wage information (gross earnings & overtime). (Referral letter to the Office of the Commissioner of Insurance.)
OCI45P We did not receive an answer to our request request for wage information (52-week gross detail). (Referral letter to the Office of the Commissioner of Insurance.)
OCI77A (PDF) We did not receive an answer to our balance due letter. (Referral letter to the Office of the Commissioner of Insurance.)
OCI86A (PDF) We did not receive an answer to our request for an updated or final WKC-13. (Referral letter to the Office of the Commissioner of Insurance.)
OCI86G (PDF) We did not receive an answer to our request for information on a first WKC-13. (Referral letter to the Office of the Commissioner of Insurance.)
OCIWGE (PDF) We did not receive an answer to our request for wage information. (Referral letter to the Office of the Commissioner of Insurance.)
SWC12 Surcharge and failure to timely file the First Report of Injury, WKC-12
SWC13 (PDF) Surcharge for failure to timely file the Supplementary WKC-13
SWC13A (PDF) Surcharge for failure to timely file the wage information required by Form WKC-13-A or an expected date.
SWC24 Surcharge and request for final medical from treating practitioner or re-estimate the date by which you expect to submit one due to one of the following: 1) received not final medical report, 2) received final medical not from treating practitioner, 3) the date you estimated to submit a final report has passed
SWC45A Surcharge and second request for wage information required by Form WKC-13-A
SWC45B Surcharge and second request for wage information (gross earnings and weeks worked)
SWC45D Surcharge and second request for wage information (part-time work information)
SWC45H Surcharge and second request for wage information (gross earnings and part-time work information)
SWC45M Surcharge and second request for wage information (gross earnings & overtime)
SWC45P Surcharge and second request for wage information (52-week gross detail)
SWC86A Surcharge and second request for an updated or final Supplemental Report, WKC-13
SWC86D Surcharge and Second request for final medical report from treating practitioner with the WKC-13
SWC86G Surcharge and Second request for overdue Supplementary WKC-13
WC45A (PDF) Your Supplementary Report, WKC-13, indicates that the wage rate is less than the maximum. This means that, in addition to filing the WKC-13, you are required to submit the wage information required by form WKC-13-A or, if that information is not immediately available, to estimate the date by which you will submit the WKC-13-A.
WC45B Wage information you submitted was incomplete. Please provide the gross taxable earnings excluding tips and the number of weeks worked and return this form immediately.
WC45C You advised us that you are paying worker’s compensation benefits at 100% of the employee's actual wage but you did not include the required self-restriction statement from the employee. Please send us a signed and dated self-restriction statement immediately.
WC45D According to our records, you submitted incomplete wage information. Please provide the information requested on part-time work and return this form immediately.
WC45H According to our records, you submitted incomplete wage information. Please provide the information requested on gross taxable earnings excluding tips, the number of weeks worked, and part-time work information. Return this form immediately.
WC45K The average weekly wage for computing temporary disability payments may be incorrect because wages at time-and-a-half were not included. Please provide the correct wage information on overtime and return this form immediately.
WC45L (PDF) We received information which indicates that the average weekly wage you used for computing the TTD rate may be incorrect. Please provide a list of the number of hours that the employee worked, week by week, during each of the 13 weeks prior to the week of injury.
WC45M According to our records, you submitted incomplete wage information. Please submit correct wage information (gross earnings and overtime) on this form.
WC45P (PDF) Submit a week-by-week list of the gross taxable earnings, excluding tips, for the 52-week period prior to the week of injury. If this employee received tips, list those separately.
WC75 The employee advised us that you have not made any disability payments on this claim since the injury. Please update us on the status of your investigation. If you made payments, please submit a Supplementary Report, WKC-13, indicating the payments to date. If you denied the claim, the Wisconsin Administrative Code requires that you give us the reason (with a copy to the employee). If you are still investigating the claim, please tell us when you expect to complete the investigation.
WC75A (PDF) According to our records, you suspended or terminated worker’s compensation payments without proper notice to the Department and the employee. If you stop payments for any reason other than an employee's return to work, you must explain why to the Department, with a copy to the employee, within 7 days.
WC77 (PDF) Our calculations of the disability amounts due and paid to date for this claim are shown below. Please pay the balance due promptly and confirm that your payment has been made by sending us an amended Supplementary Report, WKC-13, within 30 days of the date of this letter.
WC77A (PDF) Second request for payments of balance due using amended WKC-13.
WC77P According to our calculations, you paid temporary disability, but did not pay the permanent partial disability (PPD) which is due on this claim. Request for payment of permanent partial disability payments due on claim using amended WKC-13.
WC77PA Second Request for payment of partial disability payments due on claim using amended WKC-13.
WC80 (PDF) Your report on the first payment of compensation indicates that the first payment was made more than 14 days after the injury. The Worker’s Compensation law provides that, where there is an inexcusable delay, a ten (10%) percent penalty is due.
WC80P (PDF) We need to know the date and amount of the first payment of permanent partial disability.
WC86A (PDF) No recorded activity on claim for 180 days. Request current status and submit updated WKC-13 showing all dates of disability and amounts paid for each period.
WC86D The Supplementary Report, WKC-13, you submitted for this claim indicates that you made the final compensation payment for an injury which caused permanent disability or more than three weeks of temporary disability. However, you did not submit the treating practitioner's final medical report with the WKC-13 or explain why it was not submitted.
WC86E Request for comparative x-rays of both extremities for determining bone loss and permanent partial disability benefits due on this claim.
WC86K We have received a compromise or stipulation without the required Supplementary WKC-13.  Please send us a WKC-13 showing all payments to date and the dates for which these payments were made.
WC119 The purpose of this letter is to direct that you either send us a Supplementary Report, WKC-13, indicating that you adjusted payments or explain why you disagree with our computations.
WC119A Second Request for updated WKC-13 indicating wage adjustments.

When reference is made to INSLET letters it is actually referring to a dictated letter that requests information not always captured in a standard letter.

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