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Get NY C-240 2011-2024

STATE OF NEW YORK THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. WORKERS COMPENSATION BOARD EMPLOYER S STATEMENT OF WAGE EARNINGS Preceding the Date of Accident W.C. Official Title C-240 1-11 Reports should be sent directly to the Workers Compensation Board at the address listed below NYS Workers Compensation Board Centralized Mailing PO Box 5205 Binghamton NY 13902-5205 Statewide Fax Line 877-533-0337 C-240 1-11 Reverse. B. CASE NO. CARRIER S CASE NO. DATE OF ACCIDENT EMPLOYEE S SOC. SEC. NO. ADDRESS NAME APT. 5. INJURED EMPLOYEE 6. CARRIER 7. EMPLOYER 8. Employee was employed at a wage for a hourly daily weekly or monthly day week. 5 6 or 7 9. Was injured employee in military service during the 52 week period immediately preceding the date of accident Yes No If Yes give date of discharge INSTRUCTIONS 1. Give gross weekly earnings for the 52 weekly periods immediately preceding the date of accident. 2. If injured employee has not worked at the same work for a year or a substantial part thereof 234 days for a 5 day week 270 days for a 6 day week give the weekly gross earning of another employee of the same class who has worked for a year or a substantial part thereof immediately preceding the date of accident. 10. The following is a schedule of gross wage earnings for the 52 weeks immediately preceding the date of accident of Check X one The injured employee named in item 5 above. Name of employee of the same class Week No* Week Ending Date Days Worked Gross amount paid including overtime Address TOTAL 11. Was this employee given free rent lodging board tips bonus or other allowance in addition to the above earnings If Yes state weekly value thereof Describe 12. Was there any wage adjustment made affecting the 52 week period scheduled above If Yes explain I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT Prepared by Tel* No* Ext. B. CASE NO. CARRIER S CASE NO. DATE OF ACCIDENT EMPLOYEE S SOC. SEC. NO. ADDRESS NAME APT. 5. INJURED EMPLOYEE 6. CARRIER 7. EMPLOYER 8. Employee was employed at a wage for a hourly daily weekly or monthly day week. CARRIER 7. EMPLOYER 8. Employee was employed at a wage for a hourly daily weekly or monthly day week. 5 6 or 7 9. Was injured employee in military service during the 52 week period immediately preceding the date of accident Yes No If Yes give date of discharge INSTRUCTIONS 1. 5 6 or 7 9. Was injured employee in military service during the 52 week period immediately preceding the date of accident Yes No If Yes give date of discharge INSTRUCTIONS 1. Give gross weekly earnings for the 52 weekly periods immediately preceding the date of accident. 2. Give gross weekly earnings for the 52 weekly periods immediately preceding the date of accident. 2. If injured employee has not worked at the same work for a year or a substantial part thereof 234 days for a 5 day week 270 days for a 6 day week give the weekly gross earning of another employee of the same class who has worked for a year or a substantial part thereof immediately preceding the date of accident. .

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