District of Columbia Government Office of Workers325 Compensation Washington, DC 2001 (202) 671-1000 !!"#$%!&'(%)*+%! Employee Name and Address: Employer Name and Address:! Insurer Name and Address:! !!! ! ! Employer must forward to insurer copies of this schedule no later than employee325s tenth (10th) day of loss of wages. This wage schedule is for 26 weeks prior to date of injury, for wages fixed by week, month, or year, and must be filed with Office of Workers325 Compensation by insurer, together with Form No. 9 DCWC, except when maximum compensation is paid. (Wages: In addition to money payments, wages mean reasonable value of board, rent, and housing that were received from employer as well as gratuities declared for tax purposes.) Date of Hire: Date of Injury: Hourly Wages: Average Weekly Earnings: 1 2 3 4 Week Ending Gross Earnings Other Advantages (see wages definition above) Week Ending Gross Earnings Other Advantages (see wages definition above) 1 14 2 15 3 16 4 17 5 18 6 19 7 20 8 21 9 22 10 23 11 24 12 25 13 26 Total of columns 1,2,3 and 4 If wages fixed by week, month, or year, state amount per Representatives Name Signature Form No. 10 DCWC 9-222173 Date of This Report Employee Social Security No. Employer Identification No. Insurer No. ! Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. American LegalNet, Inc. www.FormsWorkFlow.com