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
We have not received the treating practitioner's final medical report for the above referenced claim which is overdue. If you do not have the final medical report yet, please explain the delay and estimate when you will submit it.
When there are more than 3 weeks of temporary disability or any permanent disability, section DWD 80.02(2)(e)4 of the Wisconsin Administrative Code requires that within 30 days after the final payment of compensation, the insurer shall submit a final treating practitioner's report together with a final WKC-13 or shall estimate when the report will be submitted. Our records indicate that final compensation was paid.
For failing to submit a timely report or a timely estimated date of submission, the Department is assessing a $100 surcharge, pursuant to s.102.35(1), Wis. Stats. Please do not pay now. The Department will record the surcharge and will invoice you annually for the total amount due.
It is important that you respond. 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 or expected date was submitted on time.
To review a complete list of reports that are due or overdue on all your claims go to "Insurer's Pending Reports" on the Department's internet web site at: http://dwd.wisconsin.gov/wc/insurance/pending_rpts.htm.
Department of Workforce Development
Worker’s Compensation Division
SWC86D (N. 02/2006)