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Full Time Wage Statement DWC-03F - Rhode Island
| Full Time Wage Statement Form. This is a Rhode Island form and can be used in Claim Department Of Labor And Training Workers Comp . |
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FULL-TIME/PART-TIME WAGE STATEMENTS (DWC-03F/DWC-03P) General Instructions: Full-time: Hired for 20 hours of more per week. (13 weeks of wages) Part-time: Hired for less than 20 hours per week. (26 weeks of wages) Completed by: Employer. Time Frame: No set time fram Howevere. , the wage statement should be comted as soon as tplehe employee has been out oorfk for w four consecutive days due to his or her work-related injury. Distribution: Original from employer to claim administrator. Claim administrator must attach to appropriate documentation when filing with DLT. Attachments: None. Definitions: PLEASE CHECK IF CORRECTION OF PRIOR REPORT: Check if sending in an amended form. 1. Employee Information: SSN: Employees Social Security Number. Name: Employees full name. Hired for: Number of hours that the employee was hired to worr week.k pe Check box if hours are not regularly scheduled but approximated. Are these supplemental wages? Yes/No:Check No if the wages are from the employewher re the employee was injured. Check Yes if the employee has more than one employer and the wageem statent is from the employer where the injury did not occur. If Yes, supplemental employer name: Name of the supplemental employer. Maximum no. of exemptions/Single or Married:Total ex emptions the employee is able to clainotm; necessarily what is on the employees W-4 form. Check appropriate marital status. 2. Claim Information: Employer: Employers actual name where the employe was ee mployed at the time of the injury. Insurance Co.: Name of the workers compensation insurer OR Self-Insu ifred the company has been certified as self-insured by D LT. Claim Administrator: Name of the WC insurace carrnier, third party administrator, or self-insured employer responsible for administering the claim. Injury Date: Date that the accident happened. Incapacity Date: First full day that the employee lost from work (include weekends and holidays). Hire Date: Date the employee began his orr he employment with the employer. 3. Employed Less Than 2 Weeks:U se this section only if the employee was employ for ed less than two full weeks. List agreed upon hourly wage:Hour ly rate of pay agreed to between employer and employee. Number of hrs. per week for full-time (part-time) employees: Enter number of hours full-tim(pare t-time) employees are generally scheduled for the employer. Multiply #1 by #2: Multiply the hourly rate by the number of scheduled hours for the average weekly wage (AWW). OR Give average weekly for same or similar employme Int:f no hourly rate was agreed upon, put the AWW for the same or similar job. 4. Employed More Than 2 Weeks:F ollow the instructions. LIST 13 (26) CONSECUTIVE WEEKS: Week Ending Date: Ending date of the weekly earnings period. No. of standard hours worked: Number of hours worked for the week listed. Gross Wages (No Overtime):Gr oss wage for the week listed. Include Suynda and Holiday pay. Do not include overtime. Total number usable weeks:Total the number of weeks led that have wages enteristed. Total Earnings: Total of wages entered. BONUS AND OVERTIME CALCULATION: Number of weeks employed(up to 52): Number of weeks the employee had been emed priploy or incapacity date. If more than 52, enter 52. Total BONUS amount paid in past 52 weeks: Total of all bonus monies paid to employee in 52 weeks prior to incapacity date. Divide Block 2 by Block 1 for average bonus: Divide total bonus monies by number of weeks employed (up to 52). Total OVERTIME amount paid in past 52 weeks: Total of all overtime monies paid to employee in 52 weeks prior to incapacity date. Divide Block 4 by Block 1 for average overtime: Divide total overtime monies by number of weeks employed (up to 52). CALCULATION OF AVERAGE WEEKLY WAGE(AWW): 1. Total earnings from 13 (26) weeksEnter the total e: arnings from the lft side of the wage estatement. 2. Total number usable weeks: Enter the total the number of usable weeks from the left side of the wage statement. 3. Divide total earnings by number of usable weeks: Enter calculation. 4. Average bonus: Enter the calculation from Block 3 above. 5. Add 3 and 4 for AWW excluding Overtime: Enter calculation. 6. Average overtime: Enter calculation from Block 5 above. 7. Add 5 and 6 for Total Average Weekly Wage: Enter calculation. Print Preparer Name/Date: Clearly enter the name of the person who filled out the form and the date that the form was prepa red. Print Adjuster Name/Date: Clearly enter the name of the adjuster who cheked the calculations on the formc and the date signed. More wage calculation tips. <<<<<<<<<********>>>>>>>>>>>>> 2 WAGE CALCULATION TIPS When a wage statement arrives at DLT, Division of Workers Compensation from the claim administrator, each one is calculated separately to ensure accuracy. If incorrect, a letter is sent to the claim administrator who must contact the employer to get the corrections; the corrections go to theback claim administrator ad again n are sent to DLT. To avoid this lengthy process and promote prompt payment to the injured worker, please review these tips. Be ready to prepare a wage statement as soon as the employee has been out of work for 4 calendar days. A delay in completing the wage statement can lead to problems with a claim. Know which wage statement to use and have it available. Do not wait for the claim administrator to send you the wage statement. Use the Full-time for a person hired for 20 hours or more per week. Part-time for a person hired for less than 20 hours per week. Seasonal for a person hired to work for 16 weeks or less. The same rules for completion apply to the full-time and the part-time wage statements. The seasonal wage statement is different (seeSea sonal Wage Statement instructions). Complete all areas of the wage statement you may n reaolize the mt any uses for a single number or date. Be sure to include the number of hopeurs r week the employee was hired to work. Injury date and Incapacity date are very important. Incapacity date is the first full calendar day that the employee was out of work due to their injury. Hire date must be provided it is used for several reasons. Use the correct section depending on whether the employee worked less or more than 2 weeks. USE CONSECUTIVE WEEKS ALWAYS whether the employee earned money or not. COMPLETE ALL COLUMNS. Skipping weeks and incomplete columns are two troublesome errors. Weeks go backwards from the incapacity date not the injury date. EX: Injury date: 5/1
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