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:

The Wage Information Supplement, form WKC-13-A, you submitted was incomplete. Please provide the information requested below and return this form to the Worker’s Compensation Division immediately.

Gross Earnings:

  1. 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? ___________________
  2. 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.

Wage Analyst
608-266-3264

WC45B

(R. 4/22/98)