August 19, 1998

SAMPLE SIMPLE
666 WC WAY
MADISON WI 53707

WC CLAIM NO: 9999-999999
INJURY DATE: 03/30/86
EMPLOYE: SIMPLE, SAMPLE
EMPLOYER: SIMPLE SAMPLE EMPLOYER
INSURER NO:

We have not received a final medical report from your doctor indicating your permanent disability, a return to work date or a date of maximum medical improvement.

Please ask your doctor for a final evaluation. Send the medical report to the worker’s compensation insurance company listed below.

If we do not hear from you or the insurance company in 30 days, we will assume you are not making a further worker’s compensation claim now.

GL10

Carbon Copy sent to:

SAMPLE INSURANCE CO
C/O SAMPLE INSURANCE CO
%W C DIVISION
204 E WASHINGTON #161
MADISON WI 53720