Form 76 Wca - Wage Schedule 1990

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THE STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
CONCORD, NH 03301
WAGE SCHEDULE
Employee_________________________________________________________
EMPLOYER MUST FORWARD TO
(Name)
INSURANCE CARRIER BOTH
Date of hire_________ Wages per hour_______ Avg. wkly. earnings_________
COPIES OF THIS SCHEDULE AND
CARRIER’S COPY OF THE
Employer_________________________________________________________
SUPPLEMENTAL REPORT FORM
(Name)
NO. 13 WCA NO LATER THAN
Address___________________________________________________________
EMPLOYEE’S FIFTEENTH DAY OF
(No.)
(Street)
(City – State)
DISBAILITY RESULTING FROM
INDUSTRIAL ACCIDENT.
THIS WAGE SCHEDULE IS FOR 26 WEEKS PRIOR TO DATE OF INJURY AND MUST BE FILED WITH
DEPARTMENT OF LABOR BY INSURANCE CARRIER TOGETHER WITH 9 WCA
1
2
3
WEEK ENDING
OTHER ADVANTAGES
TOTAL
GROSS EARNINGS
(See Wages Definition)
Columns 1 & 2
1
2
WAGES:
3
4
In addition to money
5
payments, means resonable
6
value of board, rent, housing,
7
lodging, fuel or similar
advantage received from the
8
employer, and gratuities
9
received in the course of
10
employment for others, but
11
not including any sum paid by
the employer to cover any
12
special expenses entailed on
13
the employee by the nature of
14
his employment.
15
Please provide a brief
16
explanation for weeks with no
17
wages.
18
19
RSA 281-A:2, Par. XV.
20
21
22
23
24
25
26
Carrier Name____________________________________________ __________________________________________
(Employer’s Signature)
Address________________________________________________ __________________________________________
(Title)
Dept. Approval__________________________________________ Date _____________________________________
76 WCA (12-90)
White – Labor Dept. (Mail to Carrier)
Canary – Insurance Carrier (Mail to Carrier)

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