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.

We received wage information that indicates that the average weekly wage used for computing the TTD/PPD rate(s) may be incorrect. For verification of the correct average weekly wage, please submit:

A week-by week listing of gross taxable earnings for the 52-week period ending immediately prior to the week in which the injury occurred. Include earnings for overtime, bonuses, incentive or performance pay, commissions and all other taxable earnings excluding tips.

If the employee received tips, send a week-by-week list of the tips reported.

If the employee worked for this employer less then 52 weeks prior to the week of injury, list earnings from the date of hire.

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

OCI45P (N. 03/2006)