Kentucky > Workers Comp
Average Weekly Wage Certification AWW-1 - Kentucky
| Average Weekly Wage Certification Form. This is a Kentucky form and can be used in Workers Comp . |
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Form AWW-1 Average We ekly Wage Certification Adopted January 1, 1997 KENTUCKY DEPARTMENT OF WORKERS CLAIMS CLAIM NUMBER PLAINTIFFVS WAGE CERTIFICATION DEFENDANTS1. Date of Inury/j Exposure as reported on Form 101/102/103: 2. Method of Wage Payment (check one): Hourly Daily Weekly Salary Monthly Salary Yearly Salary Output of Employee 3. Date of Hire or Employment: 4. Status or Classification of Employment (check one): Part-time Full-time Probationary Seasonal Volunteer Apprentice/Trainee 5. Did Employer provide any of the following (check appropriate ones): Board Rent Housing Lodging Fuel 6. Did Employee (check appropriate ones): Work Overtime Receive Gratuities Paid Vacations/Holidays <<<<<<<<<********>>>>>>>>>>>>> 2 Claimants Name: Claim Number: Weeks Worked # of Regular # of Overtime Regular Weekly Wage Month/Day/Year Hours Worked Hours Worked Hourly Rate 1. + x = 2. + x = 3. + x = 4. + x = 5. + x = 6. + x = 7. + x = 8. + x = 9. + x = 10. + x = 11. + x = 12. + x = 13. + x = Total: $ skee By 13 w = $ 14. + x = 15. + x = 16. + x = 17. + x = 18. + x = 19. + x = 20. + x = 21. + x = 22. + x = 23. + x = 24. + x = 25. + x = 26. + x = Total: $ skee By 13 w = $ <<<<<<<<<********>>>>>>>>>>>>> 3 Claimants Name: Claim Number: Weeks Worked # of Regular # of Overtime Regular Weekly Wage Month/Day/Year Hours Worked Hours Worked Hourly Rate 27. + x = 28. + x = 29. + x = 30. + x = 31. + x = 32. + x = 33. + x = 34. + x = 35. + x = 36. + x = 37. + x = 38. + x = 39. + x = Total: $ skee By 13 w = $ 40. + x = 41. + x = 42. + x = 43. + x = 44. + x = 45. + x = 46. + x = 47. + x = 48. + x = 49. + x = 50. + x = 51. + x = 52. + x = Total: $ skee By 13 w = $ <<<<<<<<<********>>>>>>>>>>>>> 4 CERTIFICATION I hereby certify that the above wage information is a true aaccund rate accounting of thewages of (claimants name) from the date of employment orfifty-two weeks prior to the date of the iury/nj last exposure as set forth in the Form 101/102/103,whichever is shorter. Name of Company Signature Title Date CERTIFICATE It is hereby certified that the original of this wage certification was mailed this dayof , 200__ to the Commissioner and a copy of the same to Counsel of record andthe assigned Administrative Law Judge. Attorney for Defendant Employer
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