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Injured Worker Earnings Statement Failure to file earnings statements may delay or adversely affect rates of compensation. Please note: If you are reporting income to BWC to set your wages but have

How to fill out injured worker earnings statement

How to fill out an injured worker earnings statement:

1. Obtain the injured worker earnings statement form from your employer or workers' compensation insurance provider.
2. Provide the worker's personal information, including their full name, contact details, and social security number.
3. Specify the injured worker's job title and description of their usual work tasks.
4. Indicate the dates of the injury and the period covered by the statement, usually starting from the date of injury until the present.
5. Fill in the worker's earnings details, such as their regular hourly or salary rate, the number of hours worked per week, and any overtime or additional compensation.
6. If there were any wage changes during the stated period, record them accordingly, such as promotions, raises, or reductions.
7. Include any paid time off, such as vacation or sick leave, as well as any fringe benefits received during the specified period.
8. Account for any wages earned from other employers or sources during the period if applicable.
9. If the injured worker is self-employed, provide detailed information about their business earnings and expenses.
10. Review the completed form for accuracy and ensure that all required sections have been filled out. Sign and date the statement before submitting it to the appropriate authority or party.

Who needs an injured worker earnings statement:

1. Employers may require an injured worker earnings statement to accurately assess the compensation or benefits owed to an injured employee.
2. Workers' compensation insurance companies often request earnings statements to determine the extent of a worker's disability and calculate appropriate payments.
3. Individuals who are pursuing a workers' compensation claim can benefit from providing an earnings statement as supporting documentation to validate lost income and potential wage loss benefits.

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