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 advised us that you are paying worker’s compensation benefits at 100% of the employe's actual wage. This is correct if at the time of the injury the employe restricted his or her availability to part-time work and was not employed elsewhere.

However, you did not include the required self-restriction statement from the employe. Please send us a self-restriction statement immediately.

If we do not receive a reply within 30 days, we will assume that the employe did not self-restrict and we will increase the weekly rate to either two-thirds of the wages for 24 hours of work (if the employe was part of a class at the time of injury) or two-thirds of the wages for full-time work (usually 40 hours).

WC45C

(R. 3/16/98)

DWD on Twitter DWD on Facebook DWD RSS Feed Email DWD DWD on YouTube DWD on Flickr