WORKERS' COMPENSATION COMMISSION
S T A T E M E N T O F W A G E I N F O R M A T I O N
The information below is provided pursuant to LE, §9-602(a)(2), Annotated Code of Maryland and COMAR 14.09.03.06.
This form should be submitted before the consideration date or to provide updated wage information.
* Was this employee provided free rent, lodging, board, tips or other allowances in addition to the above earnings?
If “yes”, the weekly or bi-weekly value must be included in the "Other Allowances" Column.
When the employee is paid weekly, complete each row for the most recent 14 weeks where wages were paid. If paid alternate weeks please
enter in the clear, even-numbered rows. If paid on any other schedule, please use the worksheet on page 2 to calculate the average weekly
wage. If less than 14 weeks were worked by the employee, use the worksheet on page 2.
0.00
1
0.00
2
0.00
3
0.00
4
0.00
5
0.00
6
0.00
7
0.00
8
0.00
9
0.00
10
0.00
11
0.00
12
0.00
13
0.00
14
0
TOTALS
0.00
0.00
0.00
divided by number weeks
14
$0.00
Average Weekly
0.00
TOTAL
=
worked (where wages are
Wage
paid/indicated)
I HEREBY CERTIFY that on this ______ day of ___________________, ______, service of
the foregoing was made in accordance with COMAR 14.09.01.03.
SUBMITTED BY:
Name
Signature
Title
Company
Street
State
ZIP Code
City
Email address
Telephone
CLEAR THIS FORM
SAVE THIS FORM
PRINT THIS FORM
WCC Form C-2 (10/2016)
10 East Baltimore Street Baltimore, Maryland 21202-1641
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