Send to workers’ compensation carrier: CLAIM # Deep East Texas Self Insurance Fund CARRIER’S CLAIM # (name and fax number of carrier)
Initial EMPLOYER’S WAGE STATEMENT FOR SCHOOL DISTRICTS Amended
The Texas Workers' Compensation Act and Division rules require an The employer shall timely file a complete wage statement in the form and manner prescribed by the Commission. employer to provide an Employer's Wage Statement to its workers' compensation insurance carrier (carrier) and the claimant or the claimant’s (1) The wage statement shall be filed (“filed” means received) with the representative, if any. The purpose of the form is to provide the employee's carrier, the claimant, and the claimant's representative (if any) within 30 days wage information to the carrier for calculating the employee's Average Weekly of the earliest of: Wage (AWW) to establish benefits due to the employee or a beneficiary. (A) the employee’s eighth day of disability; The AWW for a school district employee is computed based upon the wages (B) the date the employer is notified that the employee is entitled to earned in a week. “Wages earned in a week” are equal to the amount that income benefits; would be deducted from an employee’s salary if the employee were absent (C) the date of the employee’s death as a result of a compensable injury. from work for one week and the employee did not have personal leave to (2) The wage statement shall also be filed with the Division within seven compensate the employee for the lost wages from that week. days of receiving a request from the Division (Only When Requested). NOTE - An employer who fails without good cause to timely file a complete (3) A subsequent wage statement shall be filed with the carrier, employee, wage statement as required by the Texas Workers' Compensation Act, Texas and the employee’s representative (if any) within seven days if any Labor Code, Section 408.063(c) and Division Rule 120.4 may be assessed an information contained on the previous wage statement changes. administrative penalty not to exceed $500.00 for an initial offense and not to exceed $10,000.00 for a repeated administrative violation. All applicable TWCC rules can be found at www.dwc.state.tx.us
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:
I HEREBY CERTIFY THAT THIS WAGE STATEMENT is complete, The employee has not returned to work. OR accurate, and complies with the Texas Workers' Compensation Act and The employee returned to work on _ ____ applicable rules; and the listed wages include all pecuniary wages and without restriction. OR stipends as required by statute and rule and I understand that making a with restrictions and is earning wages of $ per misrepresentation about a workers’ compensation claim is a crime that can result in fines and/or imprisonment. week month (check one).
NOTE – Rule 120.3 requires the employer file the Supplemental Report of Signature: __ _____ Date: __ Injury (TWCC-6) to report changes in Work Status and Post-Injury Earnings.
Does the employee work continuously through the calendar year for the school district (i.e. does the employee work in the summer?) The answer to this question is not affected by whether the employee is paid over a 12 month period or over a shorter period.
YES NO. If no, what were the dates and the number of days or months the employee was scheduled to work in the current school year?
From _ / / to / / which requires the employee to work days OR months.
WRITTEN CONTRACT EMPLOYEE: an employee who EMPLOYEE WITHOUT A WRITTEN CONTRACT: has a written contract of employment with the school district Salaried: an “at-will”, “exempt” employee paid a set salary per month/year (generally that specifies amount that will be paid for completion of the personnel staff). contract and either the number of days the employee is required to work or the period of the contract. Hourly: an “at-will”, “non-exempt” employee paid on an hourly basis (generally staff such as cafeteria workers, bus drivers, janitorial workers). If the employee is employed through a written Daily: an “at will” employee employed and paid on a daily basis (generally substitute contract, complete the “Written Contract Wage teachers). Information” and the “Annual Wage Information” Other: (specify) sections on page 2.
If the employee is NOT employed through a written contract, complete the
“Wage Information for Salaried, Hourly, Daily, And Other Non-Contract
Employment” and the “Annual Wage Information” sections on page 2. 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