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:

The purpose of this letter is to request the final medical report from the treating practitioner.

The Supplementary Report, WKC-13, you submitted for this claim indicates that you made the final compensation payment for an injury which caused permanent disability or more than three weeks of temporary disability. However, you did not submit the treating practitioner's final medical report with the WKC-13 or explain why it was not submitted.

Please send us the treating practitioner's final medical report. If it is not available at this time please do all of the following:

  1. Send us the most recent medical report;
  2. Explain why you cannot submit the final treating practitioner's report; and
  3. Estimate when you will submit the final report.

If you fail within 30 days to either submit this required report or to explain why it is not being submitted the Department may assess a forfeiture of $100 under sec. 102.35(1), Wis. Stats.

WC86D

2/2/98