13 Week Wage Statement Form

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WAGE STATEMENT
EMPLOYEE____________________________________DATE OF INJURY________
EMPLOYER____________________________________
____I examined our payroll records and the following table shows the 13 weeks prior to
the date of injury, worked and the total gross wages earned (including overtime, bonus,
etc.) by the above-named employee during the period stated therein.
*If employee worked less than 13 weeks prior, the following will apply;
____I examined our payroll records and the above-named employee did not work for said
employer for a full 13 week period. Therefore, table below shows total gross wages
earned during the period stated therein.
EMPLOYER’S
SIGNATURE________________________POSITION__________________________
WEEK ENDING
DAYS WORKED
AMOUNT PAID
MONTH DATE YEAR
(GROSS)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
If you have any questions, please call:
CCMSI 913-385-1816
Fax form to: 913-385-9392
Mail form to: CCMSI
10740 Nall Ste 380
Overland Park, Ks. 66211

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