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:

You have advised us that the reason for your delay in making the first payment is that you were conducting an investigation of this claim. It is the Department’s position that an investigation of more than six weeks is unreasonable. Therefore, we are assessing you with the 10 percent delay penalty in accordance with Sec. 102.22 of the Worker’s Compensation Act.

Please make payment of $ to , and provide us with (his/her) signed receipt or a copy of the canceled check showing this payment has been made.

If you are in dispute with this penalty and wish to have a formal hearing on this matter, please advise our department in writing within 30 days.

Failure to respond to this letter may result in a default order being issued on the 10 percent delay penalty.

DEPARTMENT OF WORKFORCE DEVELOPMENT

Worker’s Compensation Division

GL58