August 19, 1998

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

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

Please submit a final medical report from the treating practitioner or re-estimate the date by which you expect to submit one.

We are sending this request because at least one of the following has occurred:

(1) We received a medical report for this claim which is "not final;"

(2) We received a final medical report which is not from the treating practitioner; (3) The date by which you estimated you would submit a final report has passed.

Also, if permanent disability is likely, please ask the treating practitioner to estimate permanent disability in the final medical report.

Failure to respond to this request within 30 days may result in 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.

GL24

2/4/98

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