April 6, 2006

TEST INSURER 2
C/O TEST INSURER 2
123 JENNIFER ST
MADISON WI 53703

WC CLAIM NO: 9999-999999              IF YOU CALL OR WRITE US
INJURY DATE: 06/01/98                     PLEASE USE WC CLAIM NO.
EMPLOYEE: SIMPLE, SAMPLE
EMPLOYER: SAMPLE EMPLOYER INC
INSURER NO: 094CBD6S8646
 

This is a request for overdue information.

The Wage Information Supplement, form WKC-13-A, has not been submitted as required in accordance with DWD 80.02(2)(c) of the Wisconsin Administrative Code. The wage information is to be submitted with the first WKC-13. Although you may have submitted an expected date, that date has now passed.

Due to your failure to reply to prior for this report, this has been referred as a complaint to the Office of the Commissioner of Insurance for further action and assistance in obtaining this required information.

Section 102.31(3) Wis. Stats provides the department may require an insurer to answer correspondence within 30 days. Any insurance carrier who refuses or fails to answer correspondence may be subject to enforcement proceedings under s. 601.64, Wis. Stats.

To submit this report electronically, or find out what other reports are overdue and to avoid surcharges and referrals to the Commissioner’s office in the future, go to the Insurer’s Pending Reports on the Worker’s Compensation website at:

http://dwd.wisconsin.gov/wc/insurance/pending_rpts.htm.

Department of Workforce Development

Worker’s Compensation Division

cc: Office of the Commissioner of Insurance

OCI45A (N.03/2006)


 Updated June 03, 2014
 Division of Worker's Compensation
 Content Contact: Bureau of Claims Management