Les Form Dwc-1a - Wage Statement - Florida Department Of Labor And Employment Security - Division Of Workers' Compensation

WAGE STATEMENT

FOR CARRIER'S DATE STAMP

REC'D BY CARRIER

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

DIVISION OF WORKERS’ COMPENSATION

NOTICE TO EMPLOYEE: If you have any questions about the information contained on this form, please contact your employer

or insurance carrier. If further assistance is needed, contact the Division's Employee Assistance Office at 1-800-342-1741.

PLEASE PRINT OR TYPE

EMPLOYEE NAME

SOCIAL SECURITY NUMBER

DATE OF ACCIDENT (mm/dd/yyyy)

EMPLOYER NAME & ADDRESS:

CONCURRENT EMPLOYER NAME & ADDRESS

ARE THE WAGES LISTED BELOW

(If applicable):

FOR A SIMILAR EMPLOYEE?

Street: ______________________________________________

Street: __________________________________________

YES

NO

City: ________________________________________________

City: ____________________________________________

SIMILAR EMPLOYEE’S NAME:

_________________

__________________

State:

Zip: _____________________

State:

Zip: _________________

TELEPHONE

TELEPHONE

SSN OF SIMILAR EMPLOYEE

EMPLOYEE’S CUSTOMARY WORK WEEK:

EMPLOYEE’S CUSTOMARY

EMPLOYEE’S CUSTOMARY

OCCUPATION OF SIMILAR EMPLOYEE

DAYS WORKED/WEEK:

HOURS WORKED/WEEK:

(ex. Saturday thru Friday – Use 7 calendar day period)

(ex. 5 days / week)

(ex. 40 hours / week)

NOTICE TO EMPLOYER: Please read all instructions on the back of this form carefully. Complete the form as fully as possible and submit it to your carrier within 14 days after

knowledge of any accident that has caused your employee to be disabled for more than 7 calendar days. If you discontinue providing any fringe benefits, you must file a

corrected Wage Statement with your carrier within 7 days of such termination, reflecting the type and amount of fringe benefits that were paid, and the last date they were

provided.

Please list wages earned for the 91 day period immediately preceding the accident.

GRATUITIES AS

FRINGE BENEFITS (employee rec’d)

DO NOT combine wages of two or more employees.

REPORTED TO THE

EMPLOYER COST ONLY

EMPLOYER IN

WEEK

# OF DAYS

# HOURS

WEEK

WORKED

WORKED

GROSS

WRITING AS

HEALTH

RENT/

TAXABLE INCOME

NO.

FROM

TO

THAT WEEK

THAT WEEK

PAY

INSURANCE

HOUSING

1

2

3

4

5

6

7

8

9

10

11

12

13

14

WILL EMPLOYER CONTINUE TO

RETURN THIS FORM TO:

TOTAL

PROVIDE ABOVE BENEFITS?

(Carrier Name, Address & Telephone#)

YES

NO

YES

NO

TOTAL FRINGE BENEFITS

$

TOTAL OF GROSS PAY, GRATUITIES AND FRINGES

$

AWW

COMP RATE

(FOR CARRIER USE ONLY)

Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company or self-insured program, files a statement of

claim containing any false or misleading information, is guilty of a felony of the third degree.

PREPARER’S NAME

TELEPHONE

DATE (mm/dd/yyyy)

LES Form DWC-1a (11/96)