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 the injury occurred, how many weeks did the employe work at the same type of employment that he or she performed at the time of the injury? _________________

What were the total earnings during those weeks? Include bonus or premium pay. Exclude Tips $ ___________________

In the 13-week period prior to the date of injury, was the employe paid premium pay or time-and-a-half pay? _____Yes ______No
If ‘yes,’ after how many hours? _________

Was the company’s or department’s work schedule for the employment at which the employe worked at the time of injury in effect for 13 or more weeks prior to the date of injury? ________Yes __________No

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

WC45M

(R. 3/16/98)

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