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Employers Statement Of Wage Earnings Preceeding The Date Of Accident Form. This is a New York form and can be use in Workers Compensation.
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Tags: Employers Statement Of Wage Earnings Preceeding The Date Of Accident, C-240, New York Workers Compensation,
STATE OF NEW YORK
THIS AGENCY EMPLOYS AND SERVES
PEOPLE WITH DISABILITIES WITHOUT
DISCRIMINATION.
WORKERS' COMPENSATION BOARD
EMPLOYER'S STATEMENT OF WAGE EARNINGS
(Preceding the Date of Accident)
1.
2.
W.C.B. CASE NO.
CARRIER'S CASE NO.
3.
4.
DATE OF ACCIDENT
EMPLOYEE'S SOC. SEC. NO.
ADDRESS
NAME
APT.
5. INJURED EMPLOYEE
6.
CARRIER
7.
EMPLOYER
8. Employee was employed at a ..........................................wage for a .......................day week.
(hourly, daily, weekly or monthly)
(5, 6 or 7)
9. Was injured employee in military service during the 52 week period immediately preceding the date of accident?..............................
If "Yes", give date of discharge..........................................................................................................................................................
INSTRUCTIONS:
1. Give gross weekly earnings for the 52 weekly periods immediately preceding the date of accident.
2. If injured employee has not worked at the same work for a year or a substantial part thereof (234 days for a 5 day week, 270 days for a 6 day week) give
the weekly gross earning of another employee of the same class who has worked for a year or a substantial part thereof immediately preceding the date
of accident.
10. The following is a schedule of gross wage earnings for the 52 weeks immediately preceding the date of accident of: (Check "X" one)
The injured employee named in item 5 above.
..............................................................................................................................................................................................
(Name of employee of the same class)
Week
No.
Week Ending
Date
Days
Worked
Gross amount paid
including overtime
Week
No.
(Address)
Week Ending
Date
Days
Worked
Gross amount paid
including overtime
Week
No.
1
19
20
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
18
36
Gross amount paid
including overtime
38
3
Days
Worked
37
2
Week Ending
Date
TOTAL
11. Was this employee given free rent, lodging, board, tips, bonus or other allowance in addition to the above earnings?...........................
If "Yes", state weekly value thereof $............................. Describe:........................................................................................................
12. Was there any wage adjustment made affecting the 52 week period scheduled above? If "Yes", explain:.............................................
....................................................................................................................................................................................................................
I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT:
Date................................................................................
Prepared by.............................................................................................
Tel. No. & Ext. ................................................................
Official Title..............................................................................................
C-240 (1-11)
www.wcb.state.ny.us
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INSTRUCTIONS TO THE EMPLOYERS
Reports should be sent directly to the district offices at these addresses:
ALBANY 12241 - 100 Broadway, Menands. (866) 750-5157 For all accidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton,
Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, W arren, W ashington.
BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (866) 802-3604 For all accidents in following counties: Broome, Chemung, Chenango, Cortland,
Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins.
BUFFALO 14203 - 295 Main Street, Suite 400. (866) 211-0645 For all accidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara.
ROCHESTER 14614 - 130 Main Street West. (866) 211-0644 For all accidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans,
Seneca, Steuben, W ayne, W yoming, Yates.
SYRACUSE 13203 - 935 James Street. (866) 802-3730 For all accidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga,
Oswego, St. Lawrence.
DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 5205, Binghamton, NY
13902-5205. NYC (800) 877-1373 Hemp. (866) 805-3630 Haup. (866) 681-5354 Peek. (866) 746-0552 For all accidents in following
counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland,Suffolk, W estchester.
Statewide Fax Line: 877-533-0337
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
C-240 (1-11) Reverse
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