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 paid this employe based on a weekly wage of $ at 66.67%. We compute the correct weekly wage to be $ at 66.67% under s. 102.11(1), Wis. Stats.

The purpose of this letter is to direct that you either send us a Supplementary Report, WKC-13, indicating that you adjusted payments or explain why you disagree with our computations.

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.

WC119

(N. 2/4/98)