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. trade or art by practical experience under the direction of a skilled crafts person or artisan.
If the employee was not employed for 13 continuous weeks before the date of injury, report the wages of an employee who has training, experience, skills & The wage information on this form is for: wages comparable to the injured employee AND who performs services/tasks The Injured Employee OR A Similar Employee (NOTE – If requested comparable in nature and in number of hours. If no similar employee exists, by the Division, the employer shall identify the similar employee whose wages were report the limited available wages earned by the injured employee prior to provided.)the injury. NOTE TO INJURED EMPLOYEE – If you were injured on or after 7/1/02, and had employment with more than one employer on the date of injury, you can provide your insurance carrier with wage information from your other employment for the carrier to include in your AWW and this may affect your benefits. Contact your carrier for additional information or call the Division at (800) 252-7031. You can also read rule 122.5 at www.tdi.state.tx.us.
DWC FORM-3 (REV 10/05) Page 1 DIVISION OF WORKERS’ COMPENSATION
Employee Name: Social Security #: Date of Injury:
- - - The employer shall report all wages earned in the 13 weeks immediately preceding the date of injury. If the employee is paid on a monthly or semi-monthly basis, the employer may provide wages for the 3 months preceding the date of injury. Monthly wages may also be converted to weekly wages by dividing the gross monthly amount by 4.34821. If the employee is paid on a biweekly basis, the employer may provide the wages for the 14 weeks preceding the date of injury. When setting the periods to report, the employer may adjust the reporting period backward slightly (up to six days) to line up the reporting timeframes with the employer’s natural pay cycle. However, the employer shall not report wages earned on or after the date of injury.
- If reporting weekly earnings, use all 13 Period Columns below. If reporting 3 months of earnings, either convert the wages to weekly earnings or use the first 3 Period Columns. If reporting 14 weeks of biweekly earnings, use the first 7 Period Columns. In all cases, indicate the dates that each period covers. Pecuniary Wages include all wages that are paid to the employee in the form of money. These include, but are not limited to: hourly, weekly, biweekly, monthly, etc. wages; salary; tips/gratuities; piecework compensation; monetary allowances; bonuses; and commissions. Earnings are reported in the periods they are earned, NOT when they are paid and some (such as bonuses and commissions) need to be prorated. Pecuniary wages don’t include payments made by an employer to reimburse the employee for the use of the employee's equipment or for paying helpers or to reimburse for travel expenses. Consider as earnings amounts from paid holidays and any vacation, personal or sick leave an employee used but not the market value of leave time earned but not used.
PERIOD # (Week #, 1 2 3 4 5 6 7 8 9 10 11 12 13 Month #, or Bi-Week #)
TO DATE: TOTALS # HOURS WORKED: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 GROSS WAGES 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 EARNED: Nonpecuniary Wages include all wages paid to the employee in a form other than money. These include, but are not limited to, the benefits listed below but do not include monetary allowances or stipends paid to allow the employee to purchase the benefits. Nonpecuniary Employer Will Employer Date Benefit Specify Value Or Amount Earned in Each Reported Period For Each Benefit Provided Prior To Injury Wage Type Provided Prior Continue To Suspended (Use the same periods as used above) To Injury? Provide? (if suspended) YES NO YES NO 1 2 3 4 5 6 7 8 9 10 11 12 13
DWC FORM-3 (REV 10/05) Page 1 DIVISION OF WORKERS’ COMPENSATION