WC-6 WAGE STATEMENT GEORGIA STATE BOARD OF WORKERS' COMPENSATION WAGE STATEMENT Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION County of Injury Address EMPLOYEE E-mail Address City State Zip Code Name Address EMPLOYER E-mail Address City State Zip Code INSURER/ SELF-INSURER CLAIMS OFFICE E-mail Address Name SBWC ID# (five digit number) Name Claims Office Address Insurer/Self-Insurer File # City State Zip Code B. COMPUTATION OF AVERAGE WEEKLY WAGE If the weekly benefit is less than the maximum, complete the schedule below for thirteen (13) weeks immediately preceding the accident. If the employee has not been in your employ for the thirteen (13) weeks, complete this schedule showing gross weekly earnings of a similar employee in the same employment. 2 13 Weeks of Employee's Wages 2 13 Weeks of a Similar Employee's Wages Wage at date of injury per week: 2 Full time weekly wage of injured employees SCHEDULE OF WEEKLY EARNINGS Week From Date MM/DD/YYYY To Date MM/DD/YYYY No. of Days Worked Gross Amount Paid Including Overtime or Extra Work Value of Additional Compensation Meals Lodging Rent Tips Other Total Earnings 1 2 3 4 5 6 7 8 9 10 11 12 13 Total Average Weekly Earnings REMARKS: C. Type or Print Name Signature REQUIRED TO COMPLETE: OFF DAYS 2 2 Mon Fri 2 2 Tue Sat 2 2 Wed Sun 2 2 Thur No Off Days Date E-mail Address Phone Number IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19). WC-6 REVISION 02/2016 6 WAGE STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com