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 Supplementary Report, WKC-13.

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.

We received a First Report of Injury, WKC-12, for this claim. We have not received a Supplementary Report, WKC-13. The Wisconsin Administrative Code requires that you submit a WKC-13 to the Department before the 30th day following the date of injury shown above. Please send us a WKC-13 showing all dates of disability and all amounts paid to date.

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

SWC86G (N. 02/2006)

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