Wage statement template 2026

1. Click ‘Get Form’ to open the wage statement template in the editor.
2. Begin by entering the employer's name and the date prepared at the top of the form. This sets the context for your wage statement.
3. Fill in the injured employee’s Social Security Number (SSN) and their name, ensuring accuracy for identification purposes.
4. Input the date of injury and IWIF claim number, which are crucial for processing claims efficiently.
5. For each of the 14 weeks prior to the accident, enter the week number, week ending date, gross salary (including overtime), and any additional income in their respective fields.
6. If applicable, document any allowances such as free rent or tips in the 'Additional Income' column to provide a complete financial picture.
7. Finally, sign and date the form at the bottom to validate your entries before submission.

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