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- Click ‘Get Form’ to open the dawnloadvideos in the editor.
- Begin by entering the 'Date of Injury' and 'Claim Number' at the top of the form. This information is crucial for processing your wage statement.
- Fill in the 'Injured Worker's Name' and 'Employer Name', along with a contact 'Telephone Number'. Ensure these details are accurate for effective communication.
- If applying for Wage Loss benefits, specify the 'FROM' and 'TO' dates of employment. This helps in determining eligibility.
- Complete sections regarding total gross wages, including overtime for six weeks prior to injury, and provide hourly rates and scheduled hours worked during the week of injury.
- Use the worksheet provided to report weekly wages for the year before the injury. Make sure to include all earnings without deductions.
- Finally, ensure that both the employer's signature and affidavit are completed accurately before submitting your form.
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