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:

We received a compromise or stipulation without the required WKC-13, Supplementary Report. Please send us a WKC-13 showing all worker's compensation payments to date and the dates for which these payments were made.

Failure to submit this required report within 30 days may result in a forfeiture of $100 under s. 102.35(1), Wis. Stats.

WC86K

4/2/98