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 you submitted, using the internet WKC-13-A format was incomplete.

Please provide the information requested below and return this form to the Worker’s Compensation Division immediately.

Gross Earnings:
1. During the 52-week period prior to the week of injury, how many weeks did the employee work at the same type of employment during the time of injury? ____________________

2. What were the employee’s total earnings during those weeks? (Include any bonus or premium, but exclude tips) $___________________

Due to your failure to reply to prior for this information, 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 find out what other reports are overdue and 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

OCI45B (N.03/2006)


 Updated June 21, 2010
 Division of Worker's Compensation
 Content Contact: Bureau of Claims Management