Wages - EMP ( March 12, 2019 ) Employer Report of Employee Earnings Instructions for the employer Please note that if you report income to BWC to set wages but have not reported the income to the Internal Revenue Service ( IRS ) as wages, BWC may notify the IRS of the discrepancy. You must complete the S even - day worksheet section below. T hen either complete and sign the Earnings s tatement w orksheet (page two of this form) , or submit a payroll report that includes the required information as described below. Report e arnings for the emp loyee beginning with the full - pay - period that ended prior to the date of injury or date of disability in an occupational disease claim using the actual end date of the pay period (not the issue date of payment ). Do not report wages earned on or after the date of injury or date of disability in an occupational disease claim. BWC includes the information below in the calculation of wages. I nclude the following information in your report or worksheet : o All gross earnings prior to any deductions such as for taxes, insurance, deferred compensation, garnishment or employee contr ibutions to retirement programs. o Paid holidays, vacation, personal or sick leave ( this is payment for time off work, not cash out of unused leave ). o Bonuses and commissions (you mu st indicate the period of time over which the bonus or commission was earned). o Allowance for meals, lodging, uniforms, tips, etc., paid in addition to wages, (report as other earnings wit h a description of the earnings). Reimbursements made to the inju red worker for meals, l odging, uniforms, travel, etc. (BWC does not consider these as earnings and so it does not include them in the calculation of wages.) DO not include them in your re port or worksheet. If you attach a payroll report that includes earni ngs that BWC does not consider gross earnings as defined above, please note on the payroll report or on a separate attached document . Report any periods the injured worker did not work. If payment was made during those periods, report the amount and desc ription of payment the injured worker received. Seven - d ay w orksheet You must provide this information even if you are providing weekl y earnings on a payroll report . Provide t he information based on pay period begin and end dates, not payment dates . Inju red worker name Claim number Date of injury Date of hire Employer name Employer phone number Employer address Employer email address If employed less than one full - pay period prior to the date o f injury, provide the information below . Number of hour s scheduled the week of the injury: Hourly rate : If employed one full - pay period or longer prior to the date of injury or date of disability in an occupati onal disease claim, provide the information below using the actual end date of the pay period (not th e date the payment was issued). What was the BEGINNING date of the last pay period prior to th e date of injury /disability ? (DD/MM/YYYY) // What was the END date of the last pay period prior to th e date o f injury /disability ? (DD/MM/YYYY) // P ayment is (check one): Weekly Biweekly Bimonthly Monthly Other (please explain) If t he pay period was weekly, what was the amount of overtime earned? $ If this pay period was not weekly , d uring the last seven calendar days of the pay period listed above, please provide the following: Regular e arnings the last seven calen dar days of that pay period : $ Overtime e arnings the last seven calendar days of that pay period: $ Signature Section I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain payment as provided by the BWC or who knowingly a ccepts payment to which that person is not entit led, is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, impriso nment or both. I am requesting BWC calculate or recalculate the full and/or average weekly wage in this claim and adjust previously paid compensation pursuant to RC 4123.52. Name of the person completing this form (printed) Date Signature Title Fax the completed form to 1 - 866 - 336 - 8352, or send it to the BWC customer service office where the claim is assigned. American LegalNet, Inc. www.FormsWorkFlow.com Wages - EMP ( March 12, 2019 ) Earnings s tatement w orksheet Injured worker name Claim number Date of injury Date of hire Employer name Employer phone number Employer address Employer email address Please see the Instructions for the employer for additional information be fore completing the w orksheet . Pay period end date : The actual end date of the pay period, not the date the payment was issued. For example, the check was issued on Jan. 25, 20 14 , for the pay period Jan. 12, 20 14 , to Jan. 18, 20 14. In this example, the pay period end date i s Jan. 18, 2014 . In addition, to determine the 52 weeks needed for this report, start with the end date of the last pay period prior to the date of injury the n count back 52 weeks. For example, the date of injury is Jan. 2, 20 14. The last pay period end da te prior to the date of injury is Dec. 21, 20 13. The injured worker was paid weekly. Therefore, the 52 weeks needed for the worksheet are the pay periods with end dates from Dec. 29, 20 12 , to Dec. 21, 20 13. This range may vary depending on the frequency of payment. Gross regular earnings : This is the hourly rate multiplied by the hours w orked, or the regular salary. Other earnings : Earnings NOT included in the gross regular earnings such as bonuses or allowances. You must include a n explanation of the other earnings in the Description of e xceptions and earnings column. Description of exceptions and earnings : You may also provide other i nformation for BWC to consider in the calculation of earnings such as periods the injured worker was laid off, on dis ability, etc. P ayment is (check one): Weekly Biweekly Bimonthly Monthly Other (please explain) Pay p eriod end date Gross regular earnings Other earnings Description of exceptions and earnings 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 American LegalNet, Inc. www.FormsWorkFlow.com Wages - EMP ( March 12, 2019 ) Injured worker name Claim number Pay p eriod end date Gross regular earnings Other earnings Description of exceptions and earnings 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Comments or other information I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a f alse statement, m isrepresentation, concealment of fact, or any other act of fraud to obtain payment as provided by the BWC or who knowingly ac cepts payment to which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate criminal p rovisions, be punished by a fine, imprisonment or both. I am requesting BWC calculate or recalculate the full and/or average weekly wage in this claim and adjust previously paid compensation pursuant to RC 4123.52. Name of the person completing thi s form (printed) Date Signature Title Fax the completed form to 1 - 866 - 336 - 8352, or send it to the BWC customer service office where the claim is assigned. American LegalNet, Inc. www.FormsWorkFlow.com