August 19, 1998
SAMPLE INSURANCE CO
C/O SAMPLE INSURANCE CO
%W C DIVISION
204 E WASHINGTON #161
MADISON WI 53720
According to our records, you submitted an incomplete Wage Information Supplement, WKC-13-A. For us to verify the correct average weekly wage for computing the TTD rate, please answer the following questions and return this form to the Workers Compensation Division within 30 days.
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 performed at the time of injury? _________________
What were the total earnings during those weeks? Include bonus or premium pay, but exclude tips. $__________________
How many hours per week was the employe usually scheduled to work? ______
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 did full-time employes 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.