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 records, the employe sustained an amputation as a result of a work-injury. To compute the permanent disability benefits due on this claim, we need to determine the employe's actual bone loss by comparing the injured and uninjured extremities. Please send us the comparative x-rays of both extremities.

If you cannot provide the x-rays at this time, please estimate when you can send them.

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.

 

WC86E

3/17/98