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 that you submit the overdue Wage Information Supplement, Form WKC-13A, for this claim.

The Wage Information Supplement you submitted, form WKC-13A, was incomplete. Again, please provide the information requested below and return this form to the Worker’s Compensation Division immediately.

Gross Earnings:

  1. During the 52-week period prior to the date of injury, how many weeks did the employee work at the same type of employment that he or she was performing at the time of injury? _________
  2. What were the employee's total earnings during those weeks? Include any bonus or premium, but exclude tips. $_________

For failing to report this required information, 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 dare 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 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

You may call a Wage Analyst one of the following numbers:  (608)261-6532 or (608)266-3264.

SWC45B (N. 02/2006)
 


 Updated June 21, 2010
 Division of Worker's Compensation
 Content Contact: Bureau of Claims Management