Send to workers’ compensation carrier: CLAIM # CARRIER’S CLAIM # (Name and fax number of carrier)
Initial Amended EMPLOYER’S WAGE STATEMENT The Texas Workers' Compensation Act and Workers’ Compensation rules require The employer shall timely file a complete wage statement in the form and manner an employer to provide an Employer's Wage Statement to its workers' prescribed by the Division. compensation insurance carrier (carrier) and the claimant or the claimant’s (1) The wage statement shall be filed (“filed” means received) with the carrier, the representative, if any. The purpose of the form is to provide the employee's wage claimant, and the claimant's representative (if any) within 30 days of the earliest of: information to the carrier for calculating the employee's Average Weekly Wage (A) the employee’s eighth day of disability; (AWW) to establish benefits due to the employee or a beneficiary. (B) the date the employer is notified that the employee is entitled to income The AWW is based on the wages the employee earned in the 13 weeks benefits; immediately preceding the date of injury (or the wage a similar employee earned if (C) the date of the employee’s death as a result of a compensable injury. the employee did not work the full 13-week period). "Wages" include all forms of (2) The wage statement shall also be filed with the Division within seven days of remuneration payable to an employee for personal services, including fringe receiving a request from the Division (Only When Requested). benefits. To simplify filing, employers may file wages in a monthly, biweekly, or weekly manner as discussed below. (3) A subsequent wage statement shall be filed with the carrier, employee, and the employee’s representative (if any) within seven days if any information contained NOTE - An employer who fails without good cause to timely file a complete wage on the previous wage statement changes (such as if the employer discontinues statement as required by the Texas Workers' Compensation Act, Texas Labor Code, providing a nonpecuniary wage that was initially continued after the date of injury). Section 408.063(c) and Worker’s Compensation Rule 120.4 may be assessed an administrative penalty not to exceed $500.00 for an initial offense and not to exceed All applicable DWC rules can be found at www.tdi.state.tx.us $10,000.00 for a repeated administrative violation.
Employee’s Name (Last, First, M.I.): Employer’s Business Name:
Employee’s Mailing Address (Street or P.O. Box): Employer’s Mailing Address (Street or P.O. Box):
City: State ZIP Code: City: State ZIP Code:
Social Security Number: Federal Tax I.D. Number:
Date of Hire: Date of Injury: Name and Phone # of Person Providing Wage Information:
As of today’s date, the employee is not back at work. OR I HEREBY CERTIFY THAT this wage statement is complete, accurate, and The employee returned to work on and is working: complies with the Texas Workers' Compensation Act and applicable rules, and the without restriction. OR listed wages include all pecuniary and nonpecuniary wages paid for (earned in) the with restrictions and is earning wages of $ per week 13 weeks prior to the date of injury (as described on page 2) and I understand that per month making a misrepresentation about a workers’ compensation claim is a crime that NOTE – Rule 120.3 requires the employer file the Supplemental Report of Injury can result in fines and/or imprisonment. (DWC FORM-6) to report changes in Work Status and Post-Injury Earnings. Signature: __________________________________ Date:
Full-time: employee who regularly works at least Part-time: Regular Course of Conduct: Minor: employee less than 18 years of age and 30 hours per week and whose schedule is comparable employee whose work history for the 12-month period not emancipated by marriage or judicial action who is to other employees of the company and/or other preceding the injury shows the person only worked also an apprentice, trainee or student. employees in the same business or vicinity who are part-time during that period. Student: employee enrolled in a course of study considered full-time. Part-time: Not Regular Course of Conduct: in high school, college or other institute of higher Seasonal: employee who as regular course of employee whose work history for the 12-month period education or technical training. conduct engages in seasonal or cyclical employment preceding the injury shows part-time and full time work Trainee: employee undergoing systematic that may or may not be agricultural in nature and that during that period. instruction and practice in some art, trade or does not continue throughout the year. Apprentice: employee who is learning a skilled profession with a view towards proficiency in it.