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 anticipated date submitted to the Division for submitting a final medical report from the treating practitioner has expired. Please submit the report or a new anticipated date for the report.

For failing to submit a timely report or a new anticipated date for the report, the Department is assessing a $100 surcharge, pursuant to s. 102.35(1), Wis. Stats. Please do not pay now. The Department will record the surcharge and will invoice you annually for the total amount due.

Failure to respond to this request within 30 days may 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., or both.

Department of Workforce Development
Worker’s Compensation Division

SWC24 (N. 02/2006)

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