Inj ured Worker Earnings Statement Wages - IW (Rev. March 12, 2019 ) Failure to file earnings statements may delay or adversely affect rates of compensation. Please note: If you are reporting income to BWC to set your wages but have not reported the income to the Internal Revenue Service (IRS) as wages, BWC may notify the I RS of the discrepancy (e.g., rental income, S - Corporation profits and partnership profits). Employment history If you were employed by more than one employer during the 52 weeks prior to your date of injury or date of disability in an occupational disease claim: List the name, address and phone number of each employer on the Injured Worker Earnings Statement (Wages - IW). If you were self - employed during this period, you must list yourself as an employer; List the dates of employment for every employer listed . You must also report if you are working for any employer(s) other than the employer for this claim. If anyone other than the employer of record in this claim employed you during the 52 weeks prior to the date of injury or occupational disease, you must p rovide earnings information related to that employment. You may submit earnings by providing copies of paystubs, a report from the employer that includes the required information as described below or by having the employer complete an Employer Report of E mployee Earnings (Wages - EMP). Information submitted must include: Earnings beginning with the full - pay period that ended prior to the date of injury or date of disability in an occupational disease. Only earnings prior to the date of injury or date of disa bility in an occupational disease. The frequency of payment, (i.e., weekly, biweekly, bimonthly, monthly, quarterly, yearly, other); The pay period begin and end dates, not the date the payment was issued. Any allowance for meals, lodging, uniforms, tips, etc. that you received in addition to your regular wages, including the amount received and the type of payment. Do not report reimbursements made to you for meals, lodging, uniforms, travel, etc. BWC does not consider reimbursements earnings for the purpo se of calculating wages. Any bonus or other lump sum payment received during the reporting period. Include the amount of the payment, the type of payment and the period of time over which you earned it. If detailed earnings such as copies of paystubs or wa ge statements are not available, you can provide other documentation such as W - 2s, 1099s or Social Security reports. If you submit a 1099, you must also submit accompanying evidence of expenses related to the earnings or submit the Wages - IW or an equivalen t statement that indicates there were no expenses related to the earnings. BWC will assume earnings submitted on a W - 2, Social Security report or 1099 were earned over the entire year unless specifically noted. Self - e mployment If you were self - employed dur ing the 52 weeks prior to the date of injury or date of disability in an occupational disease claim, you must submit: Completed and signed income tax forms (1040 with the Schedule C) for the year prior to the date of injury and, if available, the year in w hich the injury occurred. The 1040 must include the page with your signature. You can only use a joint income tax return as proof of earnings when you can distinguish your earnings from your income. If submitting a joint return, please redact the Social Security number of anyone other than you; or, Completed quarterly reports that you have submitted to the IRS or profit and loss statements from an accountant for the year of the injury; or, A signed Wages - EMP. Periods without earnings If you were n ot employed over periods of time during the 52 weeks prior to the date of injury or date of disability in an occupational disease claim , complete and sign the Wages - IW . American LegalNet, Inc. www.FormsWorkFlow.com Inj ured Worker Earnings Statement Wages - IW (Rev. March 12, 2019 ) Injured worker name Date of injury Claim number Address City/State ZIP c ode Emai l address Preferred contact number Cell Home List below the name, address, and dates of employment for all employers that employed you during the 52 weeks prior to the date of injury or date of disability in an occupational disease claim . If applicable, include self employment information. Attach an additional sheet or use multiple copies of this form, if necessary. You must submit evidence of actual earnings from these periods of employment to BWC. See the instructions for more details. Emplo yer name Address (including City, State and ZIP code) Phone number (including area code) Dates of employment Beginning date End date With your permission, BWC may clarify earnings information you submit from employers other than the emp loyer of record in this claim (check one of the options below). BWC may contact the employers listed above to obtain clarification of earnings information I have submitted. I am also granting permission to the employers named above to release earnings info pensation (BWC) or the Industrial Commission of Ohio. I understand this information is bein g released to the above - referenced entities for use in administering BWC may not contact the employers listed above to obtain clarification of earnings information I have submitted. If you are submitting a 1099 (select one) I have attached accompanying evidence of expenses with this form related to the earnings. I acknowledge there were no expenses related to the 1099 earnings. If applicable, list period(s) of time during the 52 weeks prior to your injury or date of disabilit y in an occupational disease when you did not work. For each period listed, you must include the reason you were not employed and indicate whether or not you sought employment during that time. BWC may require you to provide evidence to support the reason for the unemployment or job search efforts . Dates of un employment Reason for unemployment Did you seek employment during this period? (circle one) Beginning date End date Yes No Yes No Yes No Comments or other information I understand any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or self - insuring employers, or who knowingly accepts compensation to which that pers on is not entitled, is subject to criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. I, the above - named injured worker, also understand I am requesting BWC calculate or recalculate my full an d/or average weekly wage and adjust previously paid compensation pursuant to RC 4123.52. Signature of applicant Date Fax the completed form to 1 - 866 - 336 - 8352, or send it to the BWC service office where your claim is assigned. American LegalNet, Inc. www.FormsWorkFlow.com