Employer Report of Employee Earnings for Wage Loss Compensation BWC - 1269 (Rev. March 12, 2019 ) C - 142 Injured worker name Date of injury Claim number Injured worker email address Injured worker contact number Instructions If you are submitting copies of payroll check stubs or other proof of earnings provided to you by your current employer, then do not c omplete this form. If you are not submitting copies of payroll check stubs or other proof of earnings, complete this form as indicated below for submission of earnings for the payment of wage loss compensation. If BWC is processing your claim, fax the comp leted form to 1 - 866 - 336 - 8352, or send it to the BWC customer service office where the claim is assigned. If a self - insuring employer is processing your claim , send this form directly to your employer. To be completed by the injured worker I am requesting working wage l oss benefits from (provide specific dates) to and submitting the following evidence from my employer in support of this request. With your permission, BWC may assist you in obtaining clarification of the reported earnings below, if necessary (check one of the options below). BWC may contact the employer listed below to obtain clarification of the reported earnings information. BWC may not contact the employer listed below to obtain clarification of the re ported earnings information. I have answered the foregoing questions truthfully and completely. I am aware that any person who knowingly makes a false sta tement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as pr ovided by BWC or who knowingly accepts compensation to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate crimin al provisions, be punished by a fine, imprisonment or both. Date To be completed by the employer Provide e arning s information based on pay period begin and end d ates, not payment/check dates. Include all gross earnings for the injured worker prior to any deductions such as for taxes, garnishment, insurance or employee contributions to retirement programs. Employer name Employer phone number Address City State Nine digit ZIP code Pay period begin date: Pay period end date: Gross earnings: Pay period begin date: Pay period end date: Gross earnings: Pay period begin date: Pay period end date: Gross earnings: Pay period begin date: Pay period end date: Gross earnings: Does the paymen t information above include bonuses, commissions, allowances or other payments in addition to regular earnings? Yes or No If yes, please provide specific details about the payment in the comment box below, including th e period over which the payment was earned. You may also provide other information you wish to have considered in the calcu lation of wage loss compensation in the space below. Comments: 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, misrepre sentation, concealment of fact or any o ther act of fraud to ob tain payment as provided by BWC or who knowingly accepts payment to which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate cr iminal provisions, be punished by a fine, imprisonment or both. Signature of the person completing this report: Title: Date: American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com