Get Wage Verification Form

Completing the Wage Verification Form online is an essential process for ensuring the timely processing of disability compensation. This guide will provide you with clear and supportive instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete the online Wage Verification Form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editing tool.
2. Enter the date at the top of the form to provide a reference for when the form is completed.
3. Fill in the injured employee's name, including last name, first name, and middle initial, ensuring accuracy for identification.
4. Input the claim number associated with the employee's injury, which is crucial for record keeping.
5. Complete the D.P.T. number if applicable, and provide the social security number of the injured employee for verification purposes.
6. Record the date of injury and date of hire to establish the timeline relevant to the case.
7. Indicate whether the employee was hired to work 40 hours per week by selecting 'Yes' or 'No' and, if 'No,' specify the number of hours worked per week.
8. State the employee's wage on the date of injury and the frequency of payment (hourly, daily, weekly, or monthly) along with the effective date of that wage.
9. Detail any vacation, sick leave, or holiday pay received during the applicable twelve-week period by answering the provided questions.
10. Provide information regarding overtime or termination pay received within the twelve-week period.
11. If applicable, fill in the prior wage if the current wage was in effect for less than twelve weeks before the date of injury.
12. Note whether the employee changed jobs with different duties, hours, or pay during the twelve-week period and provide explanations if necessary.
13. Indicate if the employee earns commissions or bonuses, including the respective periods and amounts.
14. Ensure to include any declared tips for the purpose of worker's compensation, and fill in any additional information as required.
15. Complete the gross earnings section, including any overtime and other remuneration, and specify the payroll periods covered.
16. Document any absences with the corresponding dates and reasons, ensuring to use the correct coding for absences as outlined.
17. Finalize the form by signing and dating it, and provide your title, employer details, and any relevant insurance information.
18. Once all fields are filled, save your changes, and then you may download, print, or share the form as necessary.

Take action now to complete your Wage Verification Form online for a smooth claims process.