Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (3 pages including instruction sheet) (Rev. 1) STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813 INSTRUCTION SHEET FOR FORM WC-14 EMPLOYEE'S WAGE-REPORT FOR FIFTY-TWO WEEKS Instructions Please completely fill out the WC-14 EMPLOYEE'S WAGE-REPORT FOR FIFTY-TWO WEEKS FORM. The Delivery Information section below lists various delivery options. Please select the most convenient method and submit the completed form accordingly. Please remember to sign and date the form before submitting it. Delivery Information Delivery by U.S. Mail Department of Labor and Industrial Relations, Disability Compensation Division P.O. Box 3769, Honolulu, Hawaii 96812-3769 Delivery In-Person Department of Labor and Industrial Relations, Disability Compensation Division Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813 Delivery via Fax Department of Labor and Industrial Relations, Disability Compensation Division (808)586-9219 American LegalNet, Inc. www.FormsWorkFlow.com Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (3 pages including instruction sheet) (Rev. 1) STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813 FORM WC-14 EMPLOYEE'S WAGE-REPORT FOR FIFTY-TWO WEEKS EMPLOYEE'S WAGE-REPORT FOR FIFTY-TWO WEEKS PRIOR TO DATE OF INJURY Employee: SS No.: Case No.: - - Date of Injury: The above employee reported employment with your firm Under the Hawaii Workers' Compensation Law; an employee's benefits are calculated based on wages earned. Please assist us in determining benefits by completing this form Employer: Employee's Occupation: Hourly Rate: Date Employed: Presently Employed? If terminated, date: Disabled from: through: Returned to Work: Indicate the days and hours normally worked: Sunday:Monday:Tuesday:Wednesday: Thursday:Friday:Saturday: If other than the above, please indicate: Please call Records and Claims Branch at 586-91if you have Questions Employer:Telephone:() Address Date:By: (To be signed in ink) Auxiliary aids and services are available upon request. Please call: (808) 586-91; TTY (808) 586-8847; and for neighbor islands, TTY 1-888-569-6859. A request for reasonable accommodation(s) should be made no later than ten working days prior to the needed accommodation(s). It is the policy of the Department of Labor and Industrial Relations that no person shall, on the basis of race, color, sex, marital status, religion, creed, ethnic origin, national origin, age, disability, ancestry, arrest/court record, sexual orientation, and National Guard participation, be subjected to discrimination, excluded from participation in, or denied the benefits of the Department222s services, programs, activities, or employment. American LegalNet, Inc. www.FormsWorkFlow.com Employee: SS No.: Case No.: - - Date of Injury: Dates (inclusive) of each period paid for Dates (inclusive) of each period paid for From ToYearHours, Days, Weeks or month each Payment Covers Total amount paid Employee for each period Amount paid excluding overtime or extra work Overtime or extra work FromToYearHours, Days, Weeks or month each Payment Covers Total amount paid Employee for each period Amount paid excluding overtime or extra work Overtime or extra work 1 27 2 28 3 29 4 30 5 31 6 32 7 33 8 34 9 35 10 36 11 37 12 38 13 39 14 40 15 41 16 42 17 43 18 44 19 45 20 46 21 47 22 48 23 49 24 50 25 51 26 52 Total Total This statement of Employee's earnings is taken from our Payroll Records. This statement of Employee's earnings is taken from our Payroll Records. American LegalNet, Inc. www.FormsWorkFlow.com