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 an overdue final supplemental report, WKC-13, for this claim. In accordance with DWD 80.02(2)(e)4, the final supplemental report was due within 30 days of the date of final payment on this claim. Please submit a WKC-13 showing all dates of disability, the amounts paid for each period and the date of final payment.

The Department also assesses you a $100 surcharge, pursuant to s.102.35(1), Wis. Stats., for failing to file this required report timely. The surcharge is payable to the State of Wisconsin. Please do not pay now. The Department will record the surcharge and will 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 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

Department of Workforce Development
Worker’s Compensation Division

SWC86A (N. 02/2006)