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Seasonal Wage Statement DWC-03S - Rhode Island
| Seasonal 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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SEASONAL WAGE STATEMENT (DWC-03S) General Instructions: Seasonal: Hired for 16 weeks or less (52 weeks of wages) NOTEly: On used when the employee is injured on his or her seasonal job. Completed by: Employers/Insurer. 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. 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. Wages for how many employer are listed below?: Enter total number of separate employers wages are listed for on statement. 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. List 52 CONSECUTIVE weeks of gross wages for any employment held by this person within the 52 period: Week Ending Date: Ending date of the weekly earnings period. Gross Wages: Gross wage for the week listed. Include all earnings (Sunday, Holiday, Overtime, etc). Total Earnings: Total of wages entered for each column. 1. Combine total earnings listed: Enter the total earnings from both columns. 2. Divide total earnings by 52:Do the math. 3. Average Weekly Wage:Ente r 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. <<<<<<<<<********>>>>>>>>>>>>> 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: 5/10/2003; Incapacity date: 8/13/2003. Wages would go from 8/13/2003 back 13 or 26 weeks (depending o tnhe statement used). In this same example, you would not use the week of incapacity unless it was a full week worked. EX: If the employee was hired for 40 hours and wo 40rke hod urs during the week of the incapacity, that week could be used on the wage statement. If temhple oyee worked less than the 40 hours, you would not list the week, but would start with the week pus rev(iono matter how many hours worked that week). The same rule applies for the week of hire if it apears on the wap ge statement, only use it if a full week was worked. No overtime or bonus monies or hours should be listed in the 13 (26) weeks. They are calculated separately on the right side of the form. Since overtime is generally paid after 40 hours, if an employee worked more than 40 hours without earning any overtime, use the total hours and puNO OT t next to the hours. This will let others know that, although more than 40 hours are listed, no overtime is included. Common examples of what will be included in the 13 (26) weeks: Commissions Holiday Pay - except during an unpaid plant shutdown week Shift Differential Sick Pay or put UNPAID Sunday Pay Vacation Pay or put UNPAID Sick and vacation pay are included, but if the emoyee did pl not receive payment for any of those weeks which might appear, put the word UNPAID in the Gross Wages column instead of a zero. This will let others know that it was, in fact, unpaid. Otherwise, one might think that the preparer did not know that those monies are used. When determining Total number of usable weeks, add up only the weeks where wages are listed. Zero weeks are not used in the mathematical computation when getting the average weekly wage (AWW). Although only 13 or 26 weeks of wages are used, you must go back 52 weeks from the incapacity date to collect bonus and overtime monies. In Block 1of the Bonus and Overtime Calculation, remember to only use the number of weeks employed up to 52. If the employee worked for less than 52, list the actual number if greater than 52, list 52. Following the step-by step instructions on the remain
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