California Wage Statement
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1EMPLOYER
CALIFORNIA WAGE STATEMENT
CLAIM NUMBER
EMPLOYEE
California state law mandates that an employer shall provide proof of earnings for all
injured workers when the injury results in temporary disability and the employee earns
less than $735 per week. Please complete the weekly wage history below covering
DATE OF INJURY
the employee's GROSS wages for the 12 months preceding the work injury and mail
to:
COMPLETED BY
TITLE
DATE OF HIRE: _________
LAST DAY WORKED:_______________
WAS EMPLOYEE PAID FULL WAGES
EMPLOYMENT: FULL TIME ___
PART-TIME ___
TEMPORARY / SEASONAL / PERMANENT
ON THE DATE OF INJURY? Yes No
REGULAR WORK DAYS: M T W TH F S SUN
TIME START:
TIME END:
Dates Inclusive Of
Regular
Overtime
Bonus
Gross
Dates Inclusive Of
Regular
Overtime
Bonus
Gross
Each Period Paid
Wages
Wages
Each Period Paid
Wages
Wages
FROM
TO
YEAR
FROM
TO
YEAR
1
27
2
28
3
29
4
30
5
31
6
32
7
33
8
34
9
35
10
36
11
37
12
38
13
39
14
40
15
41
16
42
17
43
18
44
19
45
20
46
21
47
22
48
23
49
24
50
25
51
26
52
TOTAL ->
GROSS TOTAL ->
LODGING, MEALS, TIPS, ETC. _________________________
COMMENTS: ___________________________________________
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