Statement wage form 2026

1. Click ‘Get Form’ to open the statement wage form in the editor.
2. Begin by entering the Claim Information, including the Date of Injury/Illness and WCB Case #. Ensure all details are accurate for effective processing.
3. Fill in the Injured Worker Information section with the worker's full name, mailing address, job title, and Social Security #.
4. In the Insurer Information section, provide the insurer's name, ID, mailing address, phone number, fax number, and email address.
5. Complete the Employer Information section with your company’s name and contact details. Specify whether you are using a Federal Tax ID or SSN.
6. Indicate if payroll information is attached or completed on page 2. Answer questions regarding additional earnings and wage adjustments as applicable.
7. For Injured Worker Payroll, enter gross weekly earnings for each of the 52 weeks prior to injury. Include days paid and total gross amount paid.
8. If necessary, complete the Employee of Same Class Payroll section for comparison if the injured worker has not been employed long enough.

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