Get Wage Statement

Completing the Wage Statement online is an essential step for reporting employment details following a workplace accident. This guide will provide clear, concise instructions to help users accurately fill out each section of the form.

Follow the steps to successfully complete the Wage Statement online.

1. Click 'Get Form' button to obtain the Wage Statement and open it in the online form editor.
2. Begin by entering the employer's name and address in the designated fields. Ensure this information is accurate to avoid processing delays.
3. Next, fill in the employee's name, including their first, middle, and last name.
4. Provide the date of the accident in the month-day-year format.
5. If applicable, enter the name and address of the concurrent employer.
6. Indicate whether the wages listed below are for a similar employee by selecting 'Yes' or 'No'. If 'Yes', provide the similar employee's name, telephone number, and occupation.
7. Complete the fields for the employee's customary work week, including days worked per week and hours worked per week. Use a 7-day period for accuracy.
8. Fill in the employer's customary work week details similarly, specifying hours and days worked.
9. Report the wages earned by the employee for the 13 calendar weeks immediately preceding the accident. Do not include any wages earned during the week of the accident.
10. For each week, record the number of days and hours worked, along with the gross pay earned during that week.
11. List any fringe benefits received by the employee, including health insurance and housing.
12. At the end of the form, indicate whether the employer will continue to provide the benefits listed above, marking 'Yes' or 'No'.
13. Review all entries for accuracy. Save changes, and utilize available options to download, print, or share the completed form.

Begin completing your Wage Statement online today to ensure accurate processing of your claim.