Employer Report Of Employee Earnings - Ohio (Page 2 of 3) in pdf

Employer Report Of Employee Earnings - Ohio Page 2

Earnings statement worksheet

Injured worker name

Claim number

Date of injury

Date of hire

Employer name

Employer phone number

Employer address

Employer email address

Please see the Instructions for the employer for additional information before completing the worksheet.

Pay period end date: The actual end date of the pay period, not the date the payment was issued. For example, the check was issued on

Jan. 25, 2014, for the pay period Jan. 12, 2014, to Jan. 18, 2014. In this example, the pay period end date is Jan. 18, 2014. In addition, to

determine the 52 weeks needed for this report, start with the end date of the last pay period prior to the date of injury then count back 52

weeks. For example, the date of injury is Jan. 2, 2014. The last pay period end date prior to the date of injury is Dec. 21, 2013. The injured

worker was paid weekly. Therefore, the 52 weeks needed for the worksheet are the pay periods with end dates from Dec. 29, 2012, to Dec.

21, 2013. This range may vary depending on the frequency of payment.

Gross regular earnings: This is the hourly rate multiplied by the hours worked, or the regular salary.

Other earnings: Earnings NOT included in the gross regular earnings such as bonuses or allowances. You must include an explanation of

the other earnings in the Description of exceptions and earnings column.

Description of exceptions and earnings: You may also provide other information for BWC to consider in the calculation of earnings such

as periods the injured worker was laid off, on disability, etc.

Payment is (check one):

Weekly

Biweekly

Bimonthly

Monthly

Other ______________ (please explain)

Pay period

Gross regular

Other

Description of exceptions and earnings

end date

earnings

Wages-EMP

(Sept. 24, 2015)

Employer Report Of Employee Earnings - Ohio Page 2