Form C-94-A - Wage Statement - Ohio

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Instructions: The employer should complete and sign this Wage Statement
Wage Statement
unless the injured worker is self-employed or unemployed. If the injured
worker is self-employed or unemployed, both the Wage Statement and
the affidavit must be completed.
Failure to file wage statements may delay or stop compensation.
Date of injury
Claim number
The affidavit below may be sworn to without cost before a deputy
in a BWC local customer service office.
Injured worker's name
Employer name
Telephone number
If you are applying for wage loss benefits, please include from and to dates.
To
From
If employee was employed continuously and/or seven days prior to date of injury – answer 1 & 2. If employed less than seven days prior to date of injury – answer 3 & 4.
1. Total gross wages for six weeks
2.Gross wages (excluding overtime) for
3. Employee's hourly rate of pay the
4. Number of hours employee was
prior to injury, include overtime
seven days prior to injury (using last pay
week injury occurred
scheduled to work, week of injury
period prior to date of injury)
Use the worksheet below to report the employee's weekly wage for the year immediately prior to the date of injury, or attach a report which contains the required information.
Use total gross earnings. Make no deductions for Social Security, pensions, insurance, unemployment, etc. BWC must have an entire year to compute the rate of compen-
sation.
If the employee did not work during any period, state reason(s) below–(Personal, plant shutdown, other injury, illness, etc.)
Pay period ending
Amount
# of Days
For pay period ending
Amount
# of days
For pay period ending
Amount
# of Days
earned
worked
earned
worked
earned
worked
For self-insuring use only
FWW
AWW
If employee received meals, lodging, tips, etc. in addition to wages, describe and state weekly value.
Will employee receive any wages, meals, lodging, health and accident insurance benefits or any other employee benefits during period of disability which
are fully paid for by the employer? . . .
Yes
No
If yes, indicate period(s) and amount(s).
X
Employer signature and title
Affidavit
State of Ohio, County of____________________ SS: _________________________________ being first duly sworn,
says that the entire earnings from __________________ to _____________________ ; as listed above is correct.
If unable to write, mark must be witnessed by two persons.
Signature of applicant
Sworn to before me, and subscribed in my presence ______ day of _________________________________ ________ .
BWC-1217 (Rev. 6/30/2004)
C-94-A
Official title

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