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(3 pages including instruction sheet) (Rev. 1/18)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
FORM WC-14 EMPLOYEE'S WAGE-REPORT FOR FIFTY-TWO WEEKS
EMPLOYEE'S WAGE-REPORT FOR FIFTY-TWO WEEKS
PRIOR TO DATE OF INJURY
Employee: SS No.: Case No.:
- -
Date of Injury:
The above employee reported employment with your firm Under the Hawaii Workers' Compensation Law; an employee's
benefits are calculated based on wages earned. Please assist us in determining benefits by completing this form
Employer: Employee's Occupation: Hourly Rate:
Date Employed: Presently Employed? If terminated, date:
Disabled from: through:
Returned to Work:
Indicate the days and hours normally worked:
Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday:
If other than the above, please indicate:
Please call Records and Claims Branch
at 586-9161 if you have Questions
Employer: Telephone:
( )
Address
Date: By:
(To be signed in ink)
Auxiliary
aids and services are available upon request. Please call: (808) 586-9161; TTY (808) 586-8847; and for
neighbor islands, TTY 1-888-569-6859. A request for reasonable accommodation(s) should be made no later than ten
working days prior to the needed accommodation(s).
It is the policy of the Department of Labor and Industrial Relations that no person shall, on the basis of race, color, sex,
marital status, religion, creed, ethnic origin, national origin, age, disability, ancestry, arrest/court record, sexual orientation,
and National Guard participation, be subjected to discrimination, excluded from participation in, or denied the benefits of
the Department’s services, programs, activities, or employment.
