Wage Loss Statement for Job Search Injured worker name For week of Instructions • Use this form when requesting wage loss compensation. • BWC requires you to report all earnings, including checks, cash or other remuneration from any type of work activity or employment, including full-time, part-time, self-employment or commission work. • You must provide all information requested for each job contact. • Failure to complete the form in full could result in reductions in the benefit payable. • Attach verification of Internet contacts to this form, e.g., e-mail confirmations, electronic receipts. Have you received earnings from working during this period? Yes No Name of employer Claim number • Complete this form weekly. You should use more than one form for each week. • Submit or mail your forms to your local customer service specialist at least every four weeks. • Job searches may be subject to verification by BWC. • If your employer is self-insured, mail your completed form(s) to your self-insuring employer. If yes, amount of earnings received and type of work activity or employment $ Weekly Monthly Hourly Address City Description of job for which you applied/obtained Contact person/title Method of contact (check all that apply) Did you fill out an application? Yes No Were you granted an interview? Yes No In person E-mail/Internet Telephone Fax Regular mail Submitted resume’ Comments State Date of contact Result of contact Hired Not presently hiring Interview scheduled Other Name of employer Address City Description of job for which you applied/obtained Contact person/title Method of contact (check all that apply) Did you fill out an application? Yes No Were you granted an interview? Yes No In person E-mail/Internet Telephone Fax Regular mail Submitted resume’ Comments State City Description of job for which you applied/obtained Did you fill out an application? Yes No Were you granted an interview? Yes No In person E-mail/Internet Telephone Fax Regular mail Submitted resume’ Comments State City Description of job for which you applied/obtained Contact person/title Method of contact (check all that apply) Did you fill out an application? Yes No Were you granted an interview? Yes No In person E-mail/Internet Telephone Fax Comments Regular mail Submitted resume’ Will call Telephone number ( ) ZIP code Date of contact Result of contact Hired Not presently hiring Interview scheduled Other Name of employer Address Telephone number ( ) ZIP code Result of contact Hired Not presently hiring Interview scheduled Other Contact person/title Method of contact (check all that apply) Will call Date of contact Name of employer Address Attach a copy of your pay stub. Telephone number ( ) ZIP code State Will call Telephone number ( ) ZIP code Date of contact Result of contact Hired Not presently hiring Interview scheduled Other Will call Warning: I have answered the foregoing questions truthfully and completely. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or self-insuring employers, or who knowingly accepts compensation to which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. I hereby request payment of wage loss benefits for the period listed and certify that I have contacted each potential employer and the information listed on this job search form is correct to the best of my knowledge. Signature BWC-1268 (Rev. 3/25/2009) C-141 Date American LegalNet, Inc. www.FormsWorkFlow.com