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DATE OF B IRTH SOCIAL SECURITY NUMBER C ITY PHONE NUMBER EDUCATION LESS T HAN HIGH SCHOOL GED OR HIGH SCHOOL DIPLOMA B EYOND HIGH SCHOLL GENDER M ALE FEMALE STATE POSTAL C ODE M ARITAL STATUS M ARRIED SEPARATED NOT UNKNOWN UNKNOWN NUMBER OF DEPENDENTS Wages DATE HIRED GROSS EARNINGS FOR FOUR PAY DATE /AMOUNT DATE /AMOUNT DATE /AMOUNT DATE /AMOUNT PERIODS PRECEDING THE INJURY EMPLOYMENT STATUS FULL T IME PART T IME SEASONAL VOLUNTEER IN ADDITION TO GROSS EARNINGS CITED ABOVE W.
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