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
The Employer’s First Report of Injury or Disease (WKC-12) on this claim was not filed timely as provided for by administrative rule.
DWD 80.02(2) (a) requires that self-insured employers and insurance companies submit a first report of injury on or before the 14th day after an accident or the beginning of a disability from occupational disease. If an employer does not notify the insurance carrier of the injury until after the 14th day, the insurance carrier shall submit the WKC-12 to the Department within 7 days of receiving notice of the injury from any source.
For failing to file this required report in a timely manner, the Department is assessing you a $100 surcharge, payable to the State of Wisconsin pursuant to s.102.35(1), Wis. Stats. Please do not pay now. The Department will record the surcharge and invoice you annually for the total amount due on all surcharges assessed.
Failure to file required reports may also result in sanctions by the Worker’s Compensation Division under ss. 102.28(2)(c) or 102.31(3), Wis. Stats., or by the Office of the Commissioner of Insurance under s. 601.64 Wis. Stats. You may request a waiver of this surcharge within 45 days of the date of this letter. Please include any information that would show a mistake was made of that the report was submitted on time.
To find out what other reports are overdue and avoid surcharges in the future, go to the Worker’s Compensation web site’s Insurer’s Pending Reports at: http://dwd.wisconsin.gov/wc/insurance/pending_rpts.htm
Department of Workforce Development
Worker’s Compensation Division
SWC12 (N. 02/2006)