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Wage Statement Injured worker name Date of injury Phone number Cell number Employer name Claim number Phone number Email address Instructions for the employer Complete and sign this wage statement.

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The exact amount will be based on your wages at the time of your injury. For the first 12 weeks, you will receive 72% of your full weekly wage. After that, you will be paid 66 2/3% of your average weekly wage. Benefits will continue until you may return to your former position of employment.

Full Weekly Wage (FWW) – Your earnings for the six weeks prior to injury divided by 6 or the seven days prior to injury (excluding overtime), whichever is greater. The first 12 weeks of TTD is paid at 72% of the FWW.

Temporary Total (TT). The exact amount will be based on your wages at the time of your injury. For the first 12 weeks, you will receive 72% of your full weekly wage. After that, you will be paid 66 2/3% of your average weekly wage. Benefits will continue until you may return to your former position of employment.

What is salary continuation? Salary continuation, which are wages in place of temporary total compensation, allows an employer to pay an employee who has a lost-time claim their regular wages and benefits while they recover from a workplace injury or illness.

With the Go-Green Rebate Program, employers can receive a 1-percent premium rebate, up to $2,000 each policy year. Go-Green requires employers to use this website to: Enroll in electronic notifications and opt to receive policy notices electronically prior to completing the payroll true-up report.

Permanent partial disability awards are based on two-thirds of the injured worker's statewide average weekly wage, not to exceed a maximum one-third of the aver- age weekly wage. BWC determines the initial percentage of permanent partial impairment award based on an independent medical exam- iner's recommendation.

To calculate the six week wages, add wages for three pay periods prior to the date of injury, divide by the number of days (45, 46, or 47) in the pay period. Multiply this figure by seven. Multiply this amount by 6 for six week wage.

How does BWC evaluate a claim for settlement? BWC has no pre-set formulas for determining the settlement value of a claim. The settlement figure is the amount BWC is willing to pay you for the anticipated future cost of your claim. These costs are then pro-rated based upon the likelihood that they will occur.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232