Part Time Wage Statement
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Part Time Wage Statement Form. This is a Rhode Island form and can be use in Department Of Labor And Training Workers Comp.
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Tags: Part Time Wage Statement, DWC-03P, Rhode Island Workers Comp, Department Of Labor And Training
State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
PART-TIME WAGE STATEMENT (Hired for less than 20 hours per week)
Department of Labor and Training, Division of Workers' Compensation
DWC No.
PO Box 20190, Cranston, RI 02920-0942
Phone (401) 462-8100 TDD (401) 462-8006
Insurer File No.
1. EMPLOYEE INFORMATION:
2. CLAIM INFORMATION:
SSN
Employer
Name
Insurance Co.
Hired for________ hours each week (
Approximate)
Claim Administrator
Are these supplemental wages?
Yes
No
Single
Married
If yes, name of supplemental employer
Maximum no. of exemptions_______
Injury date
Incapacity date
Hire date
3. EMPLOYED LESS THAN 2 WEEKS:
If Yes:
OR:
1. List agreed upon hourly wage
2. Number of hrs. per week for part-time employees
3. Multiply #1 by #2 for average weekly wage
Give average weekly for same or similar employment:
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 26 CONSECUTIVE WEEKS:
Week Number
Week Ending
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
Total number
usable weeks:
Print Preparer Name:
DWC-03P (01/03)
No. of standard
hrs. worked
BONUS AND OVERTIME CALCULATION:
Gross Wages
(No Overtime)
Number of weeks employed (up to 52)
Total BONUS amount paid in past 52 weeks
Block 1
Block 2
Block 3
Divide Block 2 by Block 1 for average bonus
Block 4
Total OVERTIME amount paid in past 52 weeks
Block 5
Divide Block 4 by Block 1 for average overtime
CALCULATION OF AVERAGE WEEKLY WAGE (AWW):
1. Total earnings from 26 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)
Total earnings:
7. Add 5 and 6 for Total Average Weekly Wage
Date:
$
Print Adjuster Name:
Date:
For instructions visit our web site:
www.dlt.ri.gov/wc
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