DOL FORM 25 State File No.** Ins. Co. File No. Date of Injury Fed. ID No. (Rev. 6/10) DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION WAGE STATEMENT (Report of Employee's Wages) EMPLOYEE: EMPLOYER: INSTRUCTIONS (Read Carefully) 1. 2. 3. 4. Enter GROSS wages of employee for 12 weeks before date of accident (NOT take home pay). Do not include the week of the accident. Leave blank those weeks where the employee had excused absences for which he/she was not paid for more than � of a work week. Leave blank those weeks where you had reduced operations or a shutdown of the plant for which he/she was not paid for more than � of a work week. 5. Do not enter those weeks where an employee was on vacation for more than � of a work week. 6. If the employee earned tips, include the tips with Gross Wages earned or write them in the column marked "TIPS." 7. If room, board, lodging or other "extras" (electricity, fuel, etc.) are provided in addition to monetary wages, break it down into a weekly value, include and describe this income in column marked "EXTRAS." 8. Include any bonuses and commissions paid to the employee in addition to wages in the column marked "EXTRAS." 9. Enter the dates when your normal work week ends (not the date a check is given to the employee) and the number of hours or days worked. Week Ending Month Day Year Number of Hours or Days Worked Tips (if not included with wages) Gross Wages Extras (as in 7 or 8 above) Rate of Wage $ 1 2 3 Number of Days Hired to Work: 4 5 6 7 Number of Hours Hired to Work: 8 9 10 11 12 Was the employee paid in full for the day of the accident? When did the employee begin losing time? Day of the week the check will be mailed to the claimant or deposited in the claimant's account This is a correct statement of the employee's earnings as taken from the employer's payroll records. By: Date : Position Title: American LegalNet, Inc. www.FormsWorkFlow.com **If you do not have the state file number please contact the Department of Labor at (802) 828-2286. American LegalNet, Inc. www.FormsWorkFlow.com