State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORT FULL-TIME WAGE STATEMENT (Hired for 20 hours or more per week) Department of Labor and Training, Division of Workers' Compensation DWC No. PO Box 20190, Cranston, RI 02920-0942 1. EMPLOYEE INFORMATION: SSN Name Hired for________ hours each week ( Are these supplemental wages? If yes, supplemental employer name: Maximum no. of exemptions_______ If Yes: 1. List agreed upon hourly wage 2. Number of hrs. per week for full-time employees 3. Multiply #1 by #2 for average weekly wage Single Married Approximate) Yes No Phone (401) 462-8100 TDD (401) 462-8006 Insurer File No. 2. CLAIM INFORMATION: Employer Insurance Co. Claim Administrator Injury date Incapacity date Hire date OR: Give average weekly for same or similar employment: 3. EMPLOYED LESS THAN 2 WEEKS: 4. EMPLOYED MORE THAN 2 WEEKS: On the left side of the form, list gross wages prior to employee's first full day out of work. DO NOT include their week of hire or week of injury unless a full week was paid. DO NOT SKIP WEEKS. Please calculate any overtime and/or bonus paid SEPARATELY on the right side of the form below. LIST 13 CONSECUTIVE WEEKS: Week Number Week Ending Date No. of standard hrs. worked Gross Wages (No Overtime) BONUS AND OVERTIME CALCULATION: Number of weeks employed (up to 52) Total BONUS amount paid in past 52 weeks Divide Block 2 by Block 1 for average bonus Block 1 Block 2 Block 3 1 2 3 4 5 6 7 8 9 10 11 12 13 Total number usable weeks: Print Preparer Name: Total earnings: Date: Total OVERTIME amount paid in past 52 weeks Divide Block 4 by Block 1 for average overtime Block 4 Block 5 CALCULATION OF AVERAGE WEEKLY WAGE (AWW): 1. Total earnings from 13 weeks 2. Total number usable weeks 3. Divide total earnings by number of usable weeks 4. Average bonus (Block 3 in BONUS AND OT) 5. Add 3 and 4 for AWW excluding Overtime 6. Average overtime (Block 5 in BONUS AND OT) 7. Add 5 and 6 for Total Average Weekly Wage Print Adjuster Name: $ Date: $ DWC-03F (01/03) For instructions visit our web site: www.dlt.ri.gov/wc American LegalNet, Inc. www.FormsWorkFlow.com