August 19, 1998

ATTORNEY DAVID E SUNBY
PO BOX 1987
401 FIFTH ST
WAUSAU WI 54402

WC CLAIM NO: 9999-999999
INJURY DATE: 03/30/86
EMPLOYE: SIMPLE, SAMPLE
EMPLOYER: SIMPLE SAMPLE EMPLOYER
INSURER NO:

We received an application claiming 15 percent increased compensation for an alleged safety violation. Please advise if the claim is under Sec. 101.11 or a specific section of the Wisconsin Administrative Code, or both.

If you are claiming a violation of Sec. 101.11, advise us and the employer what the unsafe conditions of your work duties were at the time of the accident which you feel contributed to your injury.

This information is required so that your employer may know on what basis your claim is made to enable your employer to prepare a defense.

We will not schedule a hearing on increased compensation until the above information has been furnished to us and the employer.

GL39

Carbon Copy sent to:
SAMPLE INSURANCE CO
C/O SAMPLE INSURANCE CO
%W C DIVISION
204 E WASHINGTON #161
MADISON WI 53720

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