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 the Wage Information Supplement, Form WKC-13A, for this claim.

Information received indicates that the wage is less than the maximum. This means that in addition to filing the Supplementary Report (WKC-13), you are required to submit wage information (WKC-13A) – or the date you expect to submit a WKC-13A – within 30 days of the date of accident or the beginning of a disability from an occupational disease.

For failing to either file this required report or provide an expected date that it will be submitted, 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 each surcharge you incur and invoice you annually for the total amount due.

Failure to respond to this request within 30 days may result in further 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 or that the report or expected date was submitted on time.

To submit this report electronically, 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

SWC45A (N. 02/2006)

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