Form Ar-W - Wage Statement Immediately Preceding Injury Date printable pdf download

Form Ar-W - Wage Statement Immediately Preceding Injury Date

ARKANSAS WORKERS’ COMPENSATION COMMISSION

Form AR -W

324 Spring Street, Little Rock, AR 72201

Mail: P. O. Box 950, Little Rock, AR 72203-0950

Authority: Ark. Code Ann.

501-682-3930 / 1-800-622-4472

§11-9-518 Revised: 1-1-2001

WAGE STATEMENT IMMEDIATELY PRECEDING INJURY DATE

Weeks

Straight Time

Wages Paid For

Overtime Hours

Wages Paid for

AWCC No.

Worked

Straight Time

Worked

Overtine

Days

Hours

Days

Hours

Carrier Claim No.

Employee Name:

Employee S.S.No.:

Employer Name:

Employer FEIN No.:

Carrier or Self-Insured Name:

Carrier NAIC No.:

INSTRUCTIONS FOR

COMPLETING WAGE STATEMENT

(To be completed only if claimant

receives less than maximum b enefits)

In completing the W age Statement, in week

one give information for the week pr ior to

the injury and follow with preceding w eeks.

Days and hours of straight time wor k should

be given in all cases.

Explanation of time lost by employee:

Total

Form Ar-W - Wage Statement Immediately Preceding Injury Date