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:

According to our records, you submitted an incomplete Wage Information Supplement, WKC-13-A. For us to determine the correct average weekly wage for computing the TTD rate, please answer the following questions and return this form to the Worker’s Compensation Division within 30 days.

Part-time work:

How many hours per week was the employe scheduled when injured? ______

How many other employes worked the same schedule of hours per week? ______

How many full-time employes did the same type of work? ______

How many hours per week are full-time employes doing the same kind of work normally scheduled to work? ______

Thank you for your help in assuring correct compensation payments.

Failure to submit this required report within 30 days may result in a $100 forfeiture pursuant to sec. 102.35(1), Wis. Stats.

Wage Analyst
(608) 266-3264

WC45D

(N. 5/6/98)