August 19, 1998

SAMPLE INSURANCE CO
C/O SAMPLE INSURANCE CO
%W C DIVISION
204 E WASHINGTON #161
MADISON WI 53720

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 verify 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.

Gross earnings:

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. $__________________

 

Part-time work:

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.

 

Wage Analyst
(608) 266-3264

WC45H

(R. 3/5/98)