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 second request for the wage information.
We received wage information that indicates that the average weekly wage used for computing the TTD/PPD rate(s) may be incorrect. Please submit the following information for verification of the correct average weekly wage:
A week-by-week listing of gross taxable earnings for the 52-week period starting immediately prior to the week in which the injury occurred. Include earnings for overtime, bonuses, incentive or performance pay, commissions and all other taxable earnings excluding tips. If this employee received tips, send a week-by-week list of tips reported.
If the employee worked for this employer less than 52 weeks prior to the week of injury, list earnings from the date of hire.
For failing to submit this required information timely, 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 surcharges you incur and invoice you annually for the total amount due.
Failure to respond to this second 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., or both. 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.
SWC45P (N. 02/2006)