W A G E S T A T E M E N T Claim number:
A. The following table shows the days worked and the gross regular wages earned by _______________________
employed as a _______________________ during periods stated. List any overtime wages on a separate copy
of this form.
B. The injured employee did not work for employer a substantial portion of the year before the accident. The
following table shows days worked and wages earned by _______________________ another employee of same
or similar employment who did work a substantial part of the year.
Days
Gross Days Gross Days Gross
Mo Day Yr Worked Amount Mo Day Yr Worked Amount Mo Day Yr Worked Amount
1 __ ___ __ ______ ________ 19 __ ___ __ ______ ________ 37 __ ___ __ ______ ________
2 __ ___ __ ______ ________ 20 __ ___ __ ______ ________ 38 __ ___ __ ______ ________
3 __ ___ __ ______ ________ 21 __ ___ __ ______ ________ 39 __ ___ __ ______ ________
4 __ ___ __ ______ ________ 22 __ ___ __ ______ ________ 40 __ ___ __ ______ ________
5 __ ___ __ ______ ________ 23 __ ___ __ ______ ________ 41 __ ___ __ ______ ________
6 __ ___ __ ______ ________ 24 __ ___ __ ______ ________ 42 __ ___ __ ______ ________
7 __ ___ __ ______ ________ 25 __ ___ __ ______ ________ 43 __ ___ __ ______ ________
8 __ ___ __ ______ ________ 26 __ ___ __ ______ ________ 44 __ ___ __ ______ ________
9 __ ___ __ ______ ________ 27 __ ___ __ ______ ________ 45 __ ___ __ ______ ________
10 __ ___ __ ______ ________ 28 __ ___ __ ______ ________ 46 __ ___ __ ______ ________
11 __ ___ __ ______ ________ 29 __ ___ __ ______ ________ 47 __ ___ __ ______ ________
12 __ ___ __ ______ ________ 30 __ ___ __ ______ ________ 48 __ ___ __ ______ ________
13 __ ___ __ ______ ________ 31 __ ___ __ ______ ________ 49 __ ___ __ ______ ________
14 __ ___ __ ______ ________ 32 __ ___ __ ______ ________ 50 __ ___ __ ______ ________
15 __ ___ __ ______ ________ 33 __ ___ __ ______ ________ 51 __ ___ __ ______ ________
16 __ ___ __ ______ ________ 34 __ ___ __ ______ ________ 52 __ ___ __ ______ ________
17 __ ___ __ ______ ________ 35 __ ___ __ ______ ________ Total ________
18 __ ___ __ ______ ________ 36 __ ___ __ ______ ________ ________
Total ________ Total ________ ________
Grand Total ________
RATE OF WAGE OVERTIME
Per Hour ____________ Per Day ___________ Amount _____________ Hours __________
Per Week ____________ Per Month ___________
Contract of hire entered into at _______________________________________________________________________
City State
Date of hire: _______________
Was this employee given free rent, lodging, or board or other allowance? If so, state weekly value thereof: $__________
I hereby certify the above is a true and correct statement.
Dated at ______________________________ ___________________________________________________
Employer
This ____________ day of ________________, 20___ By ________________________________________________
Title
221-8779 (12/11)221-8779 (12/11)
RESET
RESET
PRINT
PRINT
SAVE
SAVE
RESET
RESET
PRINT
PRINT
SAVE
SAVE
RESET
RESET
PRINT
PRINT
SAVE
SAVE
