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.
1. During the 52-week period prior to the date the injury occurred, how many weeks did the employee work at the same type of employment that he or she performed at the time of the injury? __________
2. What were the total earnings during those weeks? Include bonus or premium pay. Exclude Tips. $__________
3. In the 13-week period prior to the date of injury, was the employee paid premium pay or time-and-a-half pay? ___ Yes ___ No
If ‘yes’, after how many hours? _____
4. Was the company’s or department’s work schedule for the employment at which the employee worked at the time of injury in effect for 13 or more weeks prior to the date of injury? ___ Yes ___ No
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 date 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'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.
SWC45M (N. 02/2006)