Insurers, including self - insured employers, must submit this form with the first WKC - 13 report for each claim where TTD is less than the maximum rate in the year the injury occurred. Read instructions on reverse carefully befo re completing. * Provision of your Social Security Number (SSN) is voluntary . Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m) , Wisconsin Statutes]. Employee Name Employee Social Security Number * Date of Injury Employer Name Name of Insurance Company or Self - Insured Employer (do not list adjusting company) Claims Handling Addre ss (number, city, state, zip code) Complete Section 4 for part - time employees (include anyone working less than 35 hours per week) before completing Sections 1 and 2.) 1. Hourly Wage Multiply Equals Add Equals a. Hourly rate at time of injury: Standard Base $ Piece Rate (if higher than the standard rate) Standard base rate plus tips Tip Rate only: $ Base + Tip $ x b. H use to set the wages) Normal scheduled hours: Includes those hours paid at time - and - a - half: (See Instructions) Actually Worked: (use with piece rate, or tips in Section 1a.) Expand to: (See Section 4) 24 Expand to Normal Full - time: Seasonal: (See instructions) 44 = c. B ase weekly rate: (See reverse for computing rates for time and a half employees) $ + d. Additional weekly compensation from Section 3 below: (exclude tips) $ = e. Average weekly earnings: (hourly) $ 2. Gross Wage Divide Equals Add Equals a. Gross taxable wages in 52 - week period prior to date of injury: (Exclude tips) $ 367 b. Number of weeks worked in 52 - week period prior to injury: = c. Base Gr oss Wage: $ + d. Additional weekly compensation from Section 3 below: $ = e. Actual average weekly earnings: $ 3. Additions to Cash Wage Received by Employee Per Week ( Mark any that apply) Free meals (Number/week) Weekly Amount $ Fuel Weekly Amount $ Room (Number of days/wk ) Weekly Amount $ Lights Weekly Amount $ Tips Amount/Week $ (Add only to Section 2d., not 1d.) Other Weekly Amount $ House or Apartment Weekly Amt $ Check if this is continued during disability Total Weekly Value: $ 4. Part - Time Employment (Worked less than 35 hrs/wk ) Divide Equals Part of Class Determination 1. Normal numbe r of hours scheduled per week: 2. Number of other part - time employees doing same work on same schedule: 367 3. Number of full - time employees doing the same type of work: = 4. Yes, p art of class (2 divided % by 3 is greater than 10%) No, not part of class (2 divided by 3 is less than 10%) (Choose a, b or c that applies) a Employee worked less than 24 hrs/wk, is part of a cla ss and does not restrict 1b above with number of scheduled hours shown as 24. b Employee worked less than 35 hours/wk, but is not part of a class and does not restrict availability for work. Check the box in Section 1b listed - - time employees normally work for the employer in this occupation. c Employee works less than 27 hrs/wk., an d restricts availability d complete all parts of Secti ons 2 and 5 using the 100% option of the result in Section 2e in Section 5b. Attach the self - restriction statement . See instructions on reverse for an exception to using 100% in Section 5b. Important: These options are the only circumstances for which you wages. Use normal hours scheduled or actual hours worked (piece rate, time and 1/2 or tip rate) in Section 1b unless 4a, 4b o r 4c applies. 5. Weekly Wage and TTD Rate Com putation Multiply Equals a. Weekly Wage ( Greater of #1 or #2 above ) $ x b. 66.67% OR 100%(see 4.c ) = c. Weekly TTD Rate : $ Insurance Claim Representative Telephone Number ( ) WKC - 13 - A (R. 0 3 /201 9 ) (See reverse side for instructions) Department of Workforce Development 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707 - 7901 Imaging Server Fax: (608) 260 - 2503 Telephone: (608) 266 - 1340 Fax: (608) 267 - 0394 http://www.dwd.wisconsin/wc e - mail: DWDDWC@dwd.wisconsin.gov WAGE INFORMATION SUPPLEMENT American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Wage Information Supplement, Form WKC - 13 - A These instructions will help you complete the WKC - 13 - A and compute the TTD rate correctly. If more help is needed, please contact a wag e specialist at (608) 266 - 1340 or send an e - mail to wcpendrpt@dwd.wisconsin.gov . Section DWD 80.02(2)(c) of the Wis. Admin. Code requires insurers, including self - insured employers, to submit this form wit hin 30 days after the injury. It must be submitted for every claim where the TTD rate is less than the maximum rate for the year the injury occurred. For a reference to the maximum rates , see our website at: https://dwd.wisconsin.gov/dwd/publications/wc/WKC - 9572 - P.pdf Section 1a - Hourly Rate at Time of Injury: Enter the standard base rate at the time of injury. Include in the hourly rate any additional hourly amounts which the em ployee received at the time of injury, e.g., shift differentials. For employees receiving time - and - a - half, enter the standard base rate, not time and a half rate. If this employee did not have an hourly rate but had a weekly, bi - weekly or monthly salary an d has scheduled hours of work, divide the salary by the number of hours worked in the pay period to arrive at the hourly rate . If an employee is paid solely by commission or by mileage or some other method where scheduled hours are not used, the TTD rate w ill be ork basis, compute the hourly piece work rate by dividing the earnings from piece work by the number of hours actually worke d while on piece rate. Exclude time and a half earnings and hours in this computation. Use the piece rate amount only if the resulting rate is higher than the standard hourly rate . If the employee received tips, compute the additional hourly amount of tips . Enter that amount next to and ng total tip earnings (only the earnings received in tips) by total hours actually worke d on a tip basis. The total hourly rate must be at least the legal minimum hourly wage. Section 1b - Hours Per Week: Enter the normal number of hours scheduled (regular fixed schedule) at the time of injury). Include the number of hours the employee is pai d at the time and a half rate. If the employee does not have regular scheduled hours, enter the number of hours which full - time employees normally work for the employer in this occupation. Include scheduled hours paid at a time - and - a - half rate in the numb - day period immediately preceding the injury, use the number of hours that is normal for full time employees for this occupation. Check the box tips. Check the 44 hours entered for employees who meet the definition of employees in s.102.11(1)( b) Wis. Stats. Seasonal employment cannot exceed 14 weeks. For part time employees, follow the instructions in Section 4. Section 1c - Base Weekly Rate: Multiply the hourly rate in Section 1a times the hours used in Section 1b. For employees who worked a t ime and a half schedule at the time of injury and at least 13 consecutive weeks immediately prior to the injury, use the foll owing formula: multiply the standard rate times the normal scheduled hours excluding those hours paid at the time - and - a - half rate; then multiply the time and a half rate times the time and a half hours, and add the two results to get the Base Weekly Rate. Sections 1d & 1e - Hourly Wages/Additions to Base Average Weekly Wages and Average Weekly Earnings: Enter here and in Section 2d (except for tips) the weekly value of any other type of compensation the employee received, as shown in Section 3. Section 2a - e Gross Wages and Average Weekly Earnings Enter the gross wages and the number of weeks the employe e worked on that job (same type of work) in the 52 - week period prior to the date of injury. When counting weeks for Section 2b, do not Include the week of injury in the 52 - week period. Count partial weeks as whole weeks. Include tips and additions to wages from Section 3 in section 2e. For employees who worked less than 6 weeks, TTD will be determined solely by the hourly rate in Se