August 19, 1998
SAMPLE INSURANCE CO
C/O SAMPLE INSURANCE CO
%W C DIVISION
204 E WASHINGTON #161
MADISON WI 53720
The Wage Information Supplement, form WKC-13-A, you submitted was incomplete. Please provide the information requested below and return this form to the Workers Compensation Division immediately.
- During the 52-week period prior to the date of injury, how many weeks did the employe work at the same type of employment that he or she was performing at the time of injury? ___________________
- What were the employe's total earnings during those weeks? Include any bonus or premium, but exclude tips. $_____________
Failure to report this required information within 30 days may result in a $100 forfeiture under s. 102.35(1), Wis. Stats.