August 19, 1998

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

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

According to our calculations (below), you paid temporary disability, but did not pay the permanent partial disability (PPD) which is due on this claim.

Please pay the balance due promptly and send us an amended Supplementary Report, WKC-13, to confirm your payment. If you disagree with our calculation of the amount due and have paid a different amount, please explain the basis for your payment on the amended WKC-13.

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.

 

WC77P

(R. 2/4/98)