Get GA WC-6 2011

WC-6 WAGE STATEMENT GEORGIA STATE BOARD OF WORKERS COMPENSATION Board Claim No. Employee Last Name Employee First Name M. 13 Weeks of Employee s Wages Wage at date of injury per week 13 Weeks of a Similar Employee s Wages Full time weekly wage of injured employees SCHEDULE OF WEEKLY EARNINGS From Date To MM/DD/YYYY Week No. of Days Worked Gross Amount Paid Including Overtime or Extra Work Value of Additional Compensation Meals Lodging Rent Tips Total Earnings Other Average Weekly Earnings REMARKS REQUIRED TO COMPLETE C. Type or Print Name OFF DAYS Signature Mon Fri Tue Sat Wed Sun Thur Phone Number IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http //www. sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO 10 000. I. Date of Injury SSN or Board Tracking A. IDENTIFYING INFORMATION County of Injury Address EMPLOYEE E-mail Address City Name State Zip Code INSURER/ SELF-INSURER SBWC ID five digit number Claims Office Address CLAIMS OFFICE Insurer/Self-Insurer File B. COMPUTATION OF AVERAGE WEEKLY WAGE If the weekly benefit is less than the maximum complete the schedule below for thirteen 13 weeks immediately preceding the accident. If the employee has not been in your employ for the thirteen 13 weeks complete this schedule showing gross weekly earnings of a similar employee in the same employment. 13 Weeks of Employee s Wages Wage at date of injury per week 13 Weeks of a Similar Employee s Wages Full time weekly wage of injured employees SCHEDULE OF WEEKLY EARNINGS From Date To MM/DD/YYYY Week No* of Days Worked Gross Amount Paid Including Overtime or Extra Work Value of Additional Compensation Meals Lodging Rent Tips Total Earnings Other Average Weekly Earnings REMARKS REQUIRED TO COMPLETE C. Type or Print Name OFF DAYS Signature Mon Fri Tue Sat Wed Sun Thur Phone Number IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http //www. sbwc*georgia*gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO 10 000. I. Date of Injury SSN or Board Tracking A. IDENTIFYING INFORMATION County of Injury Address EMPLOYEE E-mail Address City Name State Zip Code INSURER/ SELF-INSURER SBWC ID five digit number Claims Office Address CLAIMS OFFICE Insurer/Self-Insurer File B. COMPUTATION OF AVERAGE WEEKLY WAGE If the weekly benefit is less than the maximum complete the schedule below for thirteen 13 weeks immediately preceding the accident. COMPUTATION OF AVERAGE WEEKLY WAGE If the weekly benefit is less than the maximum complete the schedule below for thirteen 13 weeks immediately preceding the accident. If the employee has not been in your employ for the thirteen 13 weeks complete this schedule showing gross weekly earnings of a similar employee in the same employment. .