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Claim number: XX-XXXXXX
WAGE STATEMENT
A.
B.
Mo
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3 __
4 __
5 __
6 __
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8 __
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11 __
12 __
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SAVE
The following table shows the days worked and the gross regular wages earned by _______________________
XXX XXX
employed as a _______________________ during periods stated. List any overtime wages on a separate copy
of this form.
The injured employee did not work for employer a substantial portion of the year before the accident. The
following table shows days worked and wages earned by _______________________ another employee of same
or similar employment who did work a substantial part of the year.
Day
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Days
Yr Worked
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
Total
Gross
Amount
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
$0
________
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
Mo
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
Day
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Days
Yr Worked
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
Total
Gross
Amount
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
$________
0
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
Mo
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
Day
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Days
Yr Worked
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
__ ______
Total
Grand Total
Gross
Amount
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
________
$0
________
________
________
$0
________
RATE OF WAGE
OVERTIME
Per Hour ____________ Per Day ___________
Per Week ____________ Per Month ___________
Amount _____________ Hours __________
Contract of hire entered into at _______________________________________________________________________
City
State
Date of hire: _______________
Was this employee given free rent, lodging, or board or other allowance? If so, state weekly value thereof: $__________
I hereby certify the above is a true and correct statement.
Dated at ______________________________
___________________________________________________
Employer
This ____________ day of ________________, 20___ By ________________________________________________
Title
221-8779 (12/11)