Fillable Printable Employer’S Wage Statement (Dwc Form-003)

Employer’S Wage Statement (Dwc Form-003)

DWC FORM-003 Rev. 10/05 Page 1

Send to workers’ compensation carrier:

(Name and fax number of carrier)

CLAIM #

CARRIE R’S CLAI M #

Initial Amended

EMPLOYER’S WAGE STATEMENT (DWC Form-003)

The Texas Workers' Compensation Act and Workers’ Compensation rules

require an empl oyer to provide an Em ployer's Wage Stat ement 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 informati on to the carrier for c al culating the em ployee's A verage 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 ful l 13-week period). "Wages" i nclude

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 bel ow.

NOTE - An employer who fails without good cause to timely file a complete

wage statem ent as required by the Texas W orkers' Compensat ion Act, Texas

Labor Code, Section 408. 063(c) and Worker’s Compensation Rule 120.4 may

be assessed an administrative penalt y.

The employer shall timely file a complete wage statement in the form and

manner prescri bed by the Division.

(1) The wage statement shall be filed (“filed” means received) with the

carrier, t he claimant, and the c l aimant's representative (if any) within 30 days

of the earliest of:

(A) the employee’s eighth day of disabil ity;

(B) the date the employer is notified that the employee is entitled to

income benefits;

(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 re

presentative (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 aft er the date of injury).

All applicable DWC rules can be found at http://www.tdi.texas.gov/wc/rules/

EMPLOYEE AND EMPLO YER 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 Securit y Number:

xxx-xx-

Federal Tax I.D. Number:

Date of Hire:

Date of Injury:

Name and Phone # of Person Providing Wage Information:

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 restricti ons and is earnin g w ages 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.

I HEREBY CERTIFY THAT this wage statement is complete, accurate, and

complies with the Texas Workers' Compensation Act and applicable rules,

and the lis ted wages include all pec uniary and nonpecuniary wages paid f or

(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 cl aim is a crime that can result in fines and/or imprisonment.

Signature: __________________ ________________ Dat e: ____________

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

vicinit y who are considered full-time.

Seasonal: employee who as regular c ourse of

conduct engages in seasonal or cyclical

employm ent t hat m ay or m ay not be agricul tural 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.

Minor: employee less than 18 years of age

and not emancipated by marriage or judicial

action who is also an apprentice, trainee or

student.

Part-time: Not Regular Course of Conduct:

employee whose work history for the 12-month

period preceding the i njury sho ws part-t ime and f ull

time work during that period.

Student: employee enrolled in a course of

study in high school, college or other institute of

higher educati on or technic al trai ning.

Apprentice: employee who is learning a skilled

trade or art by practical experience under the

direction of a skilled crafts person or artis an.

Trainee: employee undergoing systematic

instruction and practice in some art, trade or

profession with a view towards proficienc y i n it.

SAME OR SIMILAR EMPLOYEE?

If the employee was not em ployed 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/t asks comparable in nature and in num ber of hours. If no similar

employee exists, report the limited av

ailable wages earned by the

injured employee prior to the injury.

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.)

NOTE TO INJURED EM PLOYEE – I f you were injured on or aft er 7/1/02, and had employment with more than one em ployer 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 addit i onal informat i on or call the Division at (800) 252-7031. You can also read rule 122.5 at http://www.tdi.texas.gov/wc/rules/

DWC FORM-003 Rev. 10/05 Page 2

WAGE INFORMATION INSTRUCTIO NS

Employee Name: Social Securit y #: 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 WAGE INFORMATION

Pecuniary Wages include all wages that are paid to the employee in the form of money. Thes e 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 t o be prorated. Pec uni ary wages don’t i nc l ude payments made by an employer to reimburse the employee for the

use of the em ployee's equipment or for paying hel pers or to reim burse for t ravel expenses. Consider as earnings amounts from paid

holidays and any vacation, personal or sick leave an empl oyee used but not the market value of leave time earned but not used.

PERIOD # (Week #,

Month #, or Bi-Week #)

FROM DATE:

TO DATE:

TOTALS

# HOURS WORKED:

GROSS WAGES

EARNED:

NONPECUNIAR Y WAG E INFORMATION

Nonpecuniary Wages include all wages paid to the employee in a form other than money. These incl ude, but are not limi ted to, the

benefits listed below but do not include monetary all owances or sti pends paid to allow the employee to pur chase the benefits.

Nonpecuniary

Wage Type

Employer

Provided Prior

To Injury?

Specify Value Or Amount Earned in Each Reported Period For Each Benefit Provided Prior To Injury

(Use the same periods as used above)

Will Employer

Continue To

Provide?

Date Benefit

Suspended

(if suspended)

YES

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 coll ects about you. Under §§552.021 and 552.023 of the Government Code, you are entit l ed to

receive and review the information. Under §559.004 of the Government Code you are entitled to have TDI-DW C correct information about you that is incorrect . For more informat i on, call the l ocal TDI -DWC

field office at 800-252-7031.