Send to workers’ compensation carrier: CLAIM # CARRIER’S CLAIM # (Name and fax number of carrier) Initial Amended EMPLOYER’S WAGE STATEMENT (DWC Form-003) The Texas Workers' Compensation Act and Workers’ Compensation rules require an employer to provide an Employer's Wage Statement to its workers' compensation insurance carrier (carrier) and the claimant or the claimant’s representative, if any. The purpose of the form is to provide the employee's wage information to the carrier for calculating the employee's Average Weekly Wage (AWW) to establish benefits due to the employee or a beneficiary. The AWW is based on the wages the employee earned in the 13 weeks immediately preceding the date of injury (or the wage a similar employee earned if the employee did not work the full 13-week period). "Wages" include all forms of remuneration payable to an employee for personal services, including fringe benefits. To simplify filing, employers may file wages in a monthly, biweekly, or weekly manner as discussed below. NOTE - An employer who fails without good cause to timely file a complete wage statement as required by the Texas Workers' Compensation Act, Texas Labor Code, Section 408.063(c) and Worker’s Compensation Rule 120.4 may be assessed an administrative penalty. The employer shall timely file a complete wage statement in the form and manner prescribed by the Division. (1) The wage statement shall be filed (“filed” means received) with the carrier, the claimant, and the claimant's representative (if any) within 30 days of the earliest of: (A) the employee’s eighth day of disability; (B) the date the employer is notified that the employee is entitled to income benefits; (C) the date of the employee’s death as a result of a compensable injury. (2) The wage statement shall also be filed with the Division within seven days of receiving a request from the Division (Only When Requested). (3) A subsequent wage statement shall be filed with the carrier, employee, and the employee’s representative (if any) within seven days if any information contained on the previous wage statement changes (such as if the employer discontinues providing a nonpecuniary wage that was initially continued after the date of injury). All applicable DWC rules can be found at www.tdi.state.tx.us EMPLOYEE AND EMPLOYER INFORMATION Employee’s Name (Last, First, M.I.): Employer’s Business Name: Employee’s Mailing Address (Street or P.O. Box): Employer’s Mailing Address (Street or P.O. Box): City: State: ZIP Code: Social Security Number: City: State: ZIP Code: Federal Tax I.D. Number: xxx-xxDate of Hire: Date of Injury: As of today’s date, the employee is not back at work. OR The employee returned to work on ____________ and is working: without restriction. OR with restrictions and is earning wages of $_____________ per week/month (circle one). NOTE – Rule 120.3 requires the employer file the Supplemental Report of Injury (DWC FORM-6) to report changes in Work Status and Post-Injury Earnings. Name and Phone # of Person Providing Wage Information: I HEREBY CERTIFY THAT this wage statement is complete, accurate, and complies with the Texas Workers' Compensation Act and applicable rules, and the listed wages include all pecuniary and nonpecuniary wages paid for (earned in) the 13 weeks prior to the date of injury (as described on page 2) and I understand that making a misrepresentation about a workers’ compensation claim is a crime that can result in fines and/or imprisonment. Signature: __________________________________ Date: ____________ EMPLOYMENT STATUS AT TIME OF INJURY (Check All That Apply) Full-time: employee who regularly works at least 30 hours per week and whose schedule is comparable to other employees of the company and/or other employees in the same business or vicinity who are considered full-time. Seasonal: employee who as regular course of conduct engages in seasonal or cyclical employment that may or may not be agricultural in nature and that does not continue throughout the year. Part-time: Regular Course of Conduct: employee whose work history for the 12-month period preceding the injury shows the person only worked part-time during that period. Part-time: Not Regular Course of Conduct: employee whose work history for the 12-month period preceding the injury shows part-time and full time work during that period. Apprentice: employee who is learning a skilled trade or art by practical experience under the direction of a skilled crafts person or artisan. SAME OR SIMILAR EMPLOYEE? The wage information on this form is for: The Injured Employee OR A Similar Employee (NOTE – If requested by the Division, the employer shall identify the similar employee whose wages were provided.) Minor: employee less than 18 years of age and not emancipated by marriage or judicial action who is also an apprentice, trainee or student. Student: employee enrolled in a course of study in high school, college or other institute of higher education or technical training. Trainee: employee undergoing systematic instruction and practice in some art, trade or profession with a view towards proficiency in it. If the employee was not employed for 13 continuous weeks before the date of injury, report the wages of an employee who has training, experience, skills & wages comparable to the injured employee AND who performs services/tasks comparable in nature and in number of hours. If no similar employee exists, report the limited available wages earned by the injured employee prior to the injury. NOTE TO INJURED EMPLOYEE – If you were injured on or after 7/1/02, and had employment with more than one employer on the date of injury, you can provide your insurance carrier with wage information from your other employment for the carrier to include in your AWW and this may affect your benefits. Contact your carrier for additional information or call the Division at (800) 252-7031. You can also read rule 122.5 at www.tdi.state.tx.us/wc/rules/. DWC FORM-003 Rev. 10/05 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Employee Name: WAGE INFORMATION INSTRUCTIONS Social Security #: Date of Injury: - The employer shall report all wages earned in the 13 weeks immediately preceding the date of injury. If the employee is paid on a monthly or semi-monthly basis, the employer may provide wages for the 3 months preceding the date of injury. Monthly wages may also be converted to weekly wages by dividing the gross monthly amount by 4.34821. If the employee is paid on a biweekly basis, the employer may provide the wages for the 14 weeks preceding the date of injury. When setting the periods to report, the employer may adjust the reporting period backward slightly (up to six days) to line up the reporting timeframes with the employer’s natural pay cycle. However, the employer shall not report wages earned on or after the date of injury. - If reporting weekly earnings, use all 13 Period Columns below. If reporting 3 months of earnings, either convert the wages to weekly earnings or use the first 3 Period Columns. If reporting 14 weeks of biweekly earnings, use the first 7 Period Columns. In all cases, indicate the dates that each period covers. Pecuniary Wages include all wages that are paid to the employee in the form of money. These include, but are not limited to: hourly, weekly, biweekly, monthly, etc. wages; salary; tips/gratuities; piecework compensation; monetary allowances; bonuses; and commissions. Earnings are reported in the periods they are earned, NOT when they are paid and some (such as bonuses and commissions) need to be prorated. Pecuniary wages don’t include payments made by an employer to reimburse the employee for the use of the employee's equipment or for paying helpers or to reimburse for travel expenses. Consider as earnings amounts from paid holidays and any vacation, personal or sick leave an employee used but not the market value of leave time earned but not used. PECUNIARY WAGE INFORMATION PERIOD # (Week #, Month #, or Bi-Week #) FROM DATE: 1 2 3 4 5 6 7 8 9 10 11 12 13 TO DATE: TOTALS # HOURS WORKED: GROSS WAGES EARNED: Nonpecuniary Wages include all wages paid to the employee in a form other than money. These include, but are not limited to, the benefits listed below but do not include monetary allowances or stipends paid to allow the employee to purchase the benefits. Will Employer Date Benefit Specify Value Or Amount Earned in Each Reported Period For Each Benefit Provided Prior To Injury Continue To Suspended (Use the same periods as used above) Provide? (if suspended) NONPECUNIARY WAGE INFORMATION Nonpecuniary Wage Type Employer Provided Prior To Injury? YES NO 1 2 3 4 5 6 7 8 9 10 11 12 13 YES NO Health Insurance Laundry/ Cleaning Clothing/ Uniforms Lodging/ Housing/ Food/ Meals Vehicle/ Fuel Other NOTE: With few exceptions, you are entitled on request to be informed about the information that TDI-DWC collects about you. Under §§552.021 and 552.023 of the Government Code, you are entitled to receive and review the information. Under §559.004 of the Government Code you are entitled to have TDI-DWC correct information about you that is incorrect. For more information, call the local TDI-DWC field office at 800-252-7031. DWC FORM-003 Rev. 10/05 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com