August 19, 1998

SAMPLE SIMPLE
666 WC WAY
MADISON WI 53707

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

The employe advised us that you have not made any disability payments on this claim since the injury. Please update us on the status of your investigation.

If you made payments, please submit a Supplementary Report, WKC-13, indicating the payments to date. If you denied the claim, the Wisconsin Administrative Code requires that you give us the reason (with a copy to the employe). If you are still investigating the claim, please tell us when you expect to complete the investigation.

The Department will assess a 10% penalty under 102.22, Wis. Stats., for inexcusable delays in making payments of $500 or more 30 days or more after the date of injury.

Failure to respond to this request within 30 days may result in sanctions by the Worker’s Compensation Division under ss. 102.28(2)(c) or 102.31(3), Wis. Stats., or by the Office of the Commissioner of Insurance, under s. 601.64 Wis. Stats., or both.

WC75

(R. 2/2/98)

Carbon Copy sent to:
SIMPLE SAMPLE EMPLOYER
201 E WASHINGTON AVE
MADISON WI 53703

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

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