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
This is the second request for this information.
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 further sanctions by the Workers 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.