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

According to our records, you submitted an incomplete Wage Information Supplement, WKC-13-A. For us to verify the correct average weekly wage for computing the TTD rate, please answer the following questions and return this form to the Worker’s Compensation Division within 30 days.

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 performed at the time of injury? ______   
  2. What were the total earnings during those weeks? Include bonus or premium pay, but exclude tips. $______

Part-time work:

  1. How many hours per week was the employee usually scheduled to work? ______
  2. How many other employees worked the same schedule of hours per week? ______
  3. How many full-time employees did the same type of work? ______
  4. How many hours per week did full-time employees work? ______

For failing to file this required report, 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.

To find out what other reports are overdue and avoid forfeitures in the future, go to the Worker's Compensation web site's Insurer 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.

SWC45H (N. 02/2006)

 


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