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. We need to determine the correct average weekly wage for computing the TTD rate. Please answer the following questions and return this form to the Worker’s Compensation Division.

  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 total earnings during those weeks? (Include bonus or premium pay, but exclude tips.) $_______
  3. In the 13-week period prior to the date of injury, was the employee paid premium pay or time-and -a-half pay? ____Yes ____No
    If 'yes' after how many hours? ________
  4. 4. Was the company's or department's work schedule for the employment at which the employee worked at the time of the injury in effect for 13 or more weeks prior to the injury? ____Yes ____No

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 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

OCI45M (N. 03/2006)

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