Form wage statement 2026

1. Click ‘Get Form’ to open the wage statement in the editor.
2. Begin by filling out the identifying information section. Enter the employee's last name, first name, middle initial, date of injury, and Social Security Number or Board Tracking Number.
3. Next, provide the county of injury and the employee's address details including city, state, and zip code. Repeat this for the employer's information.
4. In section B, compute the average weekly wage. If applicable, complete the schedule for thirteen weeks of earnings leading up to the accident. Fill in each week’s dates, number of days worked, gross amount paid (including overtime), and any additional compensation such as meals or lodging.
5. Finally, sign and date the form in section C. Ensure all required fields are completed before submission.

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