Guide Letters

GL05 WKC-13053-E - We received a Supplementary Report on Accidents and Industrial Diseases (WKC-13) for this temporary partial disability claim, but you failed to complete the Temporary Partial Disability through the Internet Pending Reports web address Pending Reports.
GL06 WKC-13054-E - We received a Supplementary Report, WKC-13, which indicates you are investigating this claim. Please update us on the status of your investigation.
GL07 (revised 05/18/2018) - According to our records, you may have some permanent disfigurement as a result of a work-related injury. In addition to any other worker's compensation benefits you received, you may be eligible for additional benefits if the disfigurement causes potential wage loss.
GL08 - Your recent payment of an advance to Sample Employee in the amount of $____ entitles you to an interest credit of $____.
GL09 - Our records show that you were entitled to permanent disability as a result of your work injury. You may be entitled to additional benefits if you were disabled before your work injury.
GL10 - We have not received a final medical report from your treating doctor regarding an end to your healing and whether or not you have any permanent disability. Please ask your doctor for a final evaluation. Have the doctor send the medical report to the worker's compensation insurance company, or self-insured employer named above.
GL100S - Thank you for your request to rescind the assessment of $100.00 surcharge. After reviewing the incoming document(s) and file, we are unable to rescind the surcharge. Even though you recently submitted the required report, I am unable to rescind the surcharge because the report was significantly overdue.
GL102 - According to our records, you are withholding fees to which the applicant's attorney may be entitled. Please do all of the following:

Send us the attorney's name, address and telephone number within 30 days.
Advise the attorney to submit the following to the Worker's Compensation Division:

A request to approve the fee.
A written justification for the fee.
A copy of the retainer agreement.

Continue to withhold the funds until the Department orders them to be released.

GL11 - The Worker's Compensation Division has been notified that you sustained a work-related injury on the date shown above. According to our records, it appears that you were not off work for more than 3 days immediately following your injury, nor did you sustain permanent disability as a result of your injury. Based on this information, compensation would not have been paid to you by the worker's compensation insurance carrier for your injury.
GL120 (revised 05/18/2018) - This letter is to advise you, as the applicant's representative in the above case, that for hearing applications received on or after August 1, 2007, a completed Certification of Readiness form must be received by the Division before the case can be scheduled for a hearing or settlement conference.
GL121 (revised 05/18/2018) - This letter is to notify you, as the applicant's representative in the above case, that a completed Certification of Readiness must be filed with the Division before this case can be scheduled for a hearing or settlement conference.
GL122 (revised 05/18/2018) - You were recently retained to represent the above named applicant in the Worker's Compensation case. This is to notify you that we require a completed Certification of Readiness before we can schedule this case for a hearing.
GL123 (revised 05/18/2018) - Approximately 90 days ago, you filed an Application for Hearing in the above-captioned case but have not yet filed the Certification of Readiness. We must receive a complete Certification of Readiness form before we can schedule this case for a hearing.
GL124 - You filed an Application for Hearing in the above-captioned case. The department (DWD) has now received and verified the Certificate of Readiness (COR) you filed and placed the case in ready for hearing status.

The case has been referred to the Office of Worker's Compensation Hearings (OWCH) to be scheduled for a hearing. Any questions about or updates regarding the scheduling of this case should be submitted to OWCH.
GL15 - Dear Dr. Example: The insurer listed below informed us that they did not receive your medical report on the treatment and present condition of the injured employee.
GL16 - The worker's compensation insurance carrier handling your claim has informed us that your weekly compensation benefits have been suspended because they have not received a current medical report on your condition, which they requested. Temporary disability benefits are not payable unless you are medically disabled and unable to work at a salary comparable to two-thirds of your previous wages.
GL17 - Enclosed is a computation of permanent partial disability. This worksheet is based on a medical report submitted by one of the parties.This worksheet is for informational purposes only. If you want a copy of the medical report, contact the opposing party.
GL18 (revised 05/18/2018) - Please advise us of the status of this file. Are you now ready for hearing? If not, when will you be ready?
GL18A (revised 05/18/2018) - We have had no reply to our recent inquiry of the status of this case. We will assume no further action is required. The Application for Hearing may be dismissed.
GL18B (revised 05/18/2018) - You informed us that a settlement of this claim was being discussed. Please advise us of the status of the discussion. If we have not heard from you within 30 days, we will schedule a formal hearing.
GL18C (revised 05/18/2018) - Approximately nine months ago, you filed an Application for Hearing in the above-captioned case but have not yet filed the Certification of Readiness. We will not schedule this case for a hearing without a complete Certification of Readiness.
GL18D - Approximately 15 months ago, you filed an Application for Hearing in the above-captioned case but have not yet filed the Certification of Readiness. We require the Certification of Readiness so that we only schedule those cases for hearing that are ready to be heard.
GL19A - In accordance with the Worker's Compensation order dated ____, and affirmed by the Labor Industry Review Commission (LIRC) order dated ____, please report to us the dates payments were made so we can determine if any LIRC interest is due.
GL19B - In accordance with the Worker's Compensation order dated ____, and affirmed by the Labor Industry Review Commission (LIRC) order dated ____, and affirmed by Circuit Court on ____, please report to us the dates and amounts of payments made so we can compute any LIRC and Court interest due.
GL21 - A Limited Compromise order was recently issued on this case. If there are other issues to be resolved by formal hearing as part of this case, please inform the Department immediately.
GL23 - Circumstances of this fatality were investigated by a safety specialist of the Department of Commerce. The investigation indicates that the fatality was caused by your failure to comply with Safety Order No. Ind. ____. If correct, you are responsible for an additional 15 percent of the death benefit. A copy of the safety specialist's report is enclosed.
GL24 - Please submit a final medical report from the treating practitioner or re-estimate the date by which you expect to submit one.

We are sending this request because at least one of the following has occurred:

We received a medical report for this claim which is "not final;"
We received a final medical report which is not from the treating practitioner;
The date by which you estimated you would submit a final report has passed.

Also, if permanent disability is likely, please ask the treating practitioner to estimate permanent disability in the final medical report.

GL27 - This case is pending an Interlocutory Order reserving jurisdiction to take action as may be required. Please advise if anything further is needed regarding the outcome of your hearing.
GL31 - You have filed an Application for Review of Compromise. Under Wisconsin Statutes 102.16(1), the review of compromise is discretionary with the Department. You are requested to submit copies of the medical reports on which you rely and the name of the witnesses you would produce, together with either their affidavits or a summary of the testimony each witness would offer.

Based upon the medical reports and the affidavits or summaries, the Department will determine whether or not a hearing should be held for review of the compromise or if the compromise should be confirmed. If the Department determines a hearing should be held, the parties will be notified.

GL33 (revised 05/18/2018) - This employee has filed an application under Section 102.35 (3), Wisconsin Statutes, alleging that you unreasonably refused to rehire him/her after an on-the-job injury.
The worker's compensation insurance carrier has no responsibility to defend or pay this claim.
GL33A (revised 05/18/2018) - This employee has filed a claim under Section 102.57, Wisconsin Statutes, alleging that his/her injury was caused by your failure to comply with Section 101.11, Wis. Stats., or a safety regulation of the Department of Workforce Development.
It is your responsibility as the employer to defend this claim.
GL34 (revised 05/18/2018) - We recently received a certified report. The Division of Hearings and Appeals requires attorneys, self-insured employers or insurance carriers to send copies of all certified Department of Workforce Development forms, which they wish to make part of the record, to the Division and all adverse parties. If you wish to offer this report into evidence at the hearing, you must forward a copy to all adverse parties.
GL35 (revised 05/18/2018) - An Application for Hearing has been filed. After review, we have no clear indication exactly what compensation is being claimed. We have no medical reports to support any award of additional compensation.
This case will be scheduled for a hearing in due course when we receive a Practitioner's Report on Accident (Department of Workforce Development Form WKC-16-B) supporting this claim.
GL35A (revised 05/18/2018) - We have sent a GL35 letter to the applicant's attorney requesting information on what compensation the applicant is claiming. The applicant or attorney is to mail to you a copy of their response. If no response is received within 90 days of this letter, advise us of that and we will consider dismissing the application without prejudice.
GL37 (revised 05/18/2018) WKC-13486-DHA-E - The above-named employee filed an Application for Hearing. The Office of Worker's Compensation Hearings (OWCH) served you with a copy of this application on September 24, 2012. Wis. Admin. Code DWD 80.05(2) provides that an Admission to Service and Answer to Application shall be filed within 20 days after the application has been served.
According to our records, you have not filed an Answer to the Application with the OWCH for the above-referenced claim. You are hereby directed to file an answer within 20 days from the date of this letter. Failure to file an answer may result in the OWCH issuing an order by default without further notice or hearing, in accordance with the application, as provided by s. 102.18(1)(a), Wis. Stats. If you believe this letter has been issued in error, please notify the OWCH in writing and attach a copy of the Answer.
GL37E (revised 05/18/2018) - The employee, Sample Sample Sample-Simples, filed an application for hearing. The Division of Hearings and Appeals served this application on February 06, 2013. Wis. Admin. Code § DWD 80.05(2) provides that an Admission to Service and Answer to Application shall be filed within 20 days after the application has been served.
According to our records the following parties have not filed an answer to the application with the Division for the above-referenced claim: Employer
GL37I (revised 05/18/2018) - The employee, Sample Sample Sample-Simples, filed an application for hearing. The Division of Hearings and Appeals served this application on February 06, 2013. Wis. Admin. Code § DWD 80.05(2) provides that an Admission to Service and Answer to Application shall be filed within 20 days after the application has been served.
According to our records, the following parties have not filed an answer to the application with the Division for the above-referenced claims: Insurance Carrier
DHA GL38 (revised 05/18/2018) - Provide the name and address of a financial institution in which a restricted account may be established.
GL38 - Provide the name and address of a financial institution in which a restricted account may be established.
GL39 (revised 05/18/2018) - If you are claiming a violation of sec. 101.11, Wis. Stats., advise us and the employer what the unsafe conditions of your work duties were at the time of the accident which you feel contributed to your injury.
GL40 - We have been advised you are receiving Social Security disability benefits. Worker's compensation payments can be reduced because of these benefits.
GL44 - Enclosed you will find a worksheet showing our computation of the Social Security Offset.
The total of the Monthly Benefit Amount (MBA) plus the Worker's Compensation benefit rate after the Social Security Offset cannot be less than the Worker's Compensation rate before offset. In this case, the Worker's Compensation rate is greater than 80 percent of the Average Current Earnings (ACE) so the rate should be used to compute the offset.
GL45 - We are unable to grant your request for postponement of this case. Due to our backlog of cases we are unable to postpone and reschedule as many times as we would like. Without extraordinary circumstances, we cannot postpone this case. The inconvenience of the attorneys or witnesses doesn't constitute extraordinary circumstances.
The hearing will be held at the time and place scheduled and you will make the necessary arrangements to present your case at that time.
GL45A - The expected date you reported for submitting the Wage Information Supplement, WKC-13A, has passed and we have no record of receiving it. Please submit the WKC-13A using the Insurers' Pending Reports.

DHA GL46 (revised 05/18/2018) - Sample Sample Sample-Simples is entitled to payments under the Wisconsin Workers Compensation Act. The applicant has indicated a preference that the amount due be placed in an interest-bearing account in your financial institution.
The restrictions on the account would be these: The applicant is entitled to withdraw $____ per month plus any interest, which the account may generate. This right of withdrawal is cumulative. Any withdrawals in excess of those amounts cannot be made without the prior written consent of a law judge or an administrator of the Division of Hearings and Appeals. This restricted account shall not be used as collateral or security for any loan, which the employee has acquired or wishes to obtain.
If you will accept the account, subject to the above restrictions, please advise the division with a copy of your letter to the applicant's attorney listed below.
GL46 - Sample Sample-Simples is entitled to payments under the Wisconsin Worker's Compensation Act. The applicant has indicated a preference that the amount due be placed in an interest-bearing account in your financial institution.

The restrictions on the account would be these: The applicant is entitled to withdraw $____ per month plus any interest, which the account may generate. This right of withdrawal is cumulative. Any withdrawals in excess of those amounts cannot be made without the prior written consent of a law judge or an administrator of the Wisconsin Worker's Compensation Division. This restricted account shall not be used as collateral or security for any loan, which the employee has acquired or wishes to obtain.

If you will accept the account, subject to the above restrictions, please advise this Department with a copy of your letter to the applicant's attorney listed below.

GL46A (revised 05/18/2018) - Sample Sample-Simples is entitled to payments under the Wisconsin Worker's Compensation Act. The applicant has indicated a preference that the amount due be placed in an interest-bearing account in your financial institution.
GL48 (revised 05/18/2018) - Attached is a practitioner's or vocational expert's certified report form for service. Under Wisconsin Statutes 102.17(1)(d), this report may now become evidence if it is received into the record at the hearing.
GL50 (revised 05/18/2018) with Attachment WKC-14747-DHA-E - Your case is deemed appropriate for an expedited hearing. However, before the claim will be given scheduling priority, you must complete the enclosed form, Request for Expedited Hearing (WKC-14747-DHA-E), and mail a copy to the Office of Worker's Compensation Hearings (OWCH) and to respondents with all questions answered and the required attachments.
GL50C (revised 05/18/2018) with Attachment WKC-14747-DHA-E - Your case is deemed appropriate for an expedited hearing. However, before the claim will be given scheduling priority, you must complete the enclosed form, Request for Expedited Hearing (WKC-14747-DHA-E), and mail a copy to the Office of Worker's Compensation Hearings (OWCH) and to respondents with all questions answered and the required attachments.
GL51 - According to the information submitted to us by the insurer handling your claim, you are a part-time employee and do not have additional employment outside of the employer at which the injury occurred. Therefore, your average weekly wage (AWW) has been calculated as and your temporary total disability (TTD) rate as $____.
GL53 - According to the Worker's Compensation Act, it is the responsibility of the employer to report an industrial injury to the worker's compensation insurance carrier by the seventh day after the injury. This is so there is no interruption in the income of the injured worker. As a result of late reporting, your employee did not receive payment timely. Therefore, we are assessing you with the 10 percent delay penalty according to sec. 102.22 of the Wisconsin Statutes.
Please make payment of $____ to Sample Sample Sample-Simples and furnish us with a copy of a signed receipt or canceled check showing this payment has been made.
GL55 - Your reason for the delay of the first compensation payment on this injury is not acceptable. Therefore, we are assessing you with the 10 percent delay penalty according to sec. 102.22 of the Wisconsin Statutes.
Please make payment of $____ to Sample Sample Sample-Simples and furnish us with a copy of a signed receipt or canceled check showing this payment has been made.
GL58 - You have advised us that the reason for your delay in making the first payment is that you were conducting an investigation of this claim. It is the Department's position that an investigation of more than six weeks is generally considered unreasonable. Therefore, we are assessing you with the 10 percent delay penalty in accordance with Sec. 102.22 of the Worker's Compensation Act.
Please make payment of $____ to Sample Sample-Simples and provide us with a revised WKC-13 reflecting payment made.
GL60 - You have advised us that you reported this claim promptly at the time of the injury. However, there was no compensable lost time at the time of the injury. You are required to report lost time to your worker's compensation insurance carrier by the seventh day of lost time. Since you did not comply with this requirement, you are being assessed with the 10 percent delay penalty in accordance with Sec. 102.22 of the Worker's Compensation Act.
Please make payment of $____ to Sample Sample Sample-Simples and provide us with a signed receipt or a copy of the canceled check showing payment made.
GL61 - You have advised us that the reason for your delay in reporting this injury is that the employee failed to fill out the forms promptly.
The Worker's Compensation Act requires that an employer file a first report of injury with their worker's compensation insurance carrier by the seventh day of lost time or within seven days of notification by the employee that an injury has occurred. Since you have not complied with this requirement, we are assessing you with the 10 percent delay penalty on this claim in accordance with Sec. 102.22 of the Worker's Compensation Act.
Please make payment of $____to Sample Sample Sample-Simples and provide us with a signed receipt or a copy of the canceled check showing this payment has been made.
GL70 - An application for compensation due to a hearing loss has been received. You should obtain a report from a physician qualified to perform an audiometric test. The physician should measure any decibel loss at the four (4) speech frequencies of 500, 1,000, 2,000 and 3,000 for both ears, prepare an audiogram and attach a completed WKC-16-B. Please have your physician answer the questions regarding the cause of any hearing loss.
GL71 - We have received an operative report or medical report assessing permanent disability as a result of this injury. Although the payment information you have submitted reflects that the injured employee lost no time from work, the medical report indicates that the employee did lose time from work either as a result of surgery or within the three-day waiting period.
GL87 - Under the provisions of Wisconsin Statutes, Sec. 102.22, interest payments as a result of the court appeal have become due as follows:
GL89 - The Worker's Compensation Division has been informed that 20 percent of the benefits are being withheld as a potential attorney's fee. If you are claiming an attorney's fee on these benefits, kindly review sec. 102.26, Wis. Stats., and sec. DWD 80.43 of the Wisconsin Administrative Code and then submit to the Division, within 30 days of the date of this letter, your full written explanation why you feel that a fee ought to be approved.
GL90 - Necessity of Treatment Dispute Resolution

The Worker's Compensation Division received your Necessity of Treatment Dispute Resolution Request relating to treatment for the injury referenced above.

However, the Department also received a formal application for hearing relating to this injury. When an employee, employer or insurance carrier requests a hearing in which the cause or extent of the injury is disputed, the Department will delay resolution of any medical cost/necessity of treatment disputes until proper liability and the degree of disability have been determined through the formal hearing process.

GL91 - RE: REASONABLENESS OF FEE DISPUTE RESOLUTION
The Worker's Compensation Division received your Health Service Cost/Reasonableness of Fee Dispute Resolution Request relating to treatment for the injury referenced above.
However, the Department also received a formal application for hearing relating to this injury. When an employee, employer or insurance carrier requests a hearing in which the cause or extent of the injury is disputed, the Department will delay resolution of any medical cost/necessity disputes until proper liability and the degree of disability have been determined through the formal hearing process.
GL92 - NECESSITY OF TREATMENT DISPUTE RESOLUTION
We have received a health cost dispute for necessity of treatment.

You have 20 days to either negotiate a settlement with the provider, pay the disputed amount or file an answer with this Department. The answer must include the name of the organization and credentials of any individual whose review of the case has been relied upon in reaching the decisions to deny payment. Your answer should also include any prior correspondence relating to the dispute which the health care provider has not already filed with us and any other material you want to be considered.
GL94 (revised 05/22/2023) - HEALTH COST DISPUTE/REASONABLENESS OF FEES
On, the Department received a reasonableness of fee dispute resolution request from for treatment from, to, in the amount of. The provider requests that the Department determine whether or not billed fee(s) are reasonable under Wis. Stat. § 102.16(2) and Wis. Admin. Code DWD § 80.72.

Pursuant to Wis. Admin. Code DWD § 80.72, Test Insurer 2 has 20 days from the date of this notice to file an answer with the Department and send a copy of the answer to the provider. The answer must include:
- The state-certified database used for reimbursement.
- Copies of prior correspondence relating to the fee dispute which the provider has not already filed. It is not necessary to include a copy of the provider's application.
- An explanation, if applicable, of why the service provided is not more difficult or complicated than in the usual case.
GL94A - On submitted to the Department a reasonableness of fee dispute resolution request for treatment provided from through. The total amount in dispute is.

The Department informed Test Insurer 2 that, pursuant to s. 102.16(2), Wis. Stats., and s. DWD 80.72 of the Wisconsin Administrative Code, it had 20 days to file an answer to the reasonableness of fee dispute resolution request filed by the provider. As of the present date, Test Insurer 2 has not responded and provided the Department with information from a database certified by the Department that the fee in dispute is greater than the formula amount in the database.
GL97 (revised 11/29/2018) - NECESSITY OF TREATMENT DISPUTE RESOLUTION
On, the Department received a necessity of treatment dispute resolution request from for dates of treatment, through, in the amount of. The provider requests that the Department issue a default order pursuant to Wis. Admin. Code DWD ? 80.73(3)(c) based on the failure of Test Insurer 2, within 60 days of receiving the provider?s bill documenting treatment, to either pay for medical treatment or to give proper notice to the provider as to why the treatment was unnecessary.

Test Insurer 2 has 20 days from the date of this notice to submit to the Department, with a copy to the provider, an explanation of the extraordinary circumstances that prevented payment or proper notice being given to the provider under Wis. Admin. Code DWD ? 80.73(3)(a). The answer can be mailed to the PO Box address or faxed to the Health Cost Dispute Unit's fax number, which are listed above. Please notify the Unit if the dispute has been resolved.
GL97A - This is a request for information.

On, submitted to the Department a necessity of treatment dispute resolution request for treatment provided from, through. The total amount in dispute is.

The Department informed Test Insurer 2 that it had 20 days to file an answer to the necessity of treatment dispute resolution request filed by the provider. As of the present date, Test Insurer 2 has not responded.
GL98 (revised 7/26/2018) - NECESSITY OF TREATMENT DISPUTE RESOLUTION
On ____, the Department received notice this health cost dispute has been resolved.
Therefore, pursuant to s. DWD 80.73(8)(c) Wis. Admin. Code, this application for necessity of treatment dispute resolution is dismissed without prejudice.
GL99 (revised 7/26/2018) - REASONABLENESS OF FEE DISPUTE RESOLUTION
On ____, the Department received notice this health cost dispute has been resolved.
Therefore, pursuant to s. DWD 80.72 Wis. Admin. Code, the application for reasonableness of fee dispute resolution is dismissed without prejudice.
GL110 - This case has been appealed to the Circuit Court. As a result of this appeal we are required to have the transcript(s) of the hearing prepared. You are being billed for the cost of the preparation of the original and two copies of the transcript(s).
GL111 - Enclosed is a copy of the transcript of testimony taken at the hearing held by Administrative Law Judge on.
GL115 (revised 06/01/2019) - REASONABLENESS OF FEE DISPUTE RESOLUTION
According to our records, Test Insurer 2 responded on January 30, 2016 indicating payment was made after the filing of the health cost dispute resolution request.
Therefore ____, is to notify the Department in writing, with a copy to Test Insurer 2, whether payment was received, and if so, whether it was to your satisfaction. Failure to respond within 30 days of this letter may result in a determination that this dispute has been resolved and a dismissal order will be issued.
GL116 (revised 07/01/2019) - NECESSITY OF TREATMENT DISPUTE RESOLUTION
According to our records, Test Insurer 2 responded on January 30, 2016 indicating payment was made after the filing of the health cost dispute resolution request.

Therefore, [name] is to notify the Department in writing, with a copy to the insurer, whether payment was received, and if so, whether it was to your satisfaction. Failure to respond within 30 days of this letter may result in a determination that this dispute has been resolved and a dismissal order will be issued.
PYMNTRECD - Enclosed is a copy of the transcript of testimony taken at the hearing held by Alj Name Administrative Law Judge on 01/01/2016.