Wisconsin > Workers Comp
Wage Information Supplement WKC-13A - Wisconsin
| Wage Information Supplement Form. This is a Wisconsin form and can be used in Workers Comp . |
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WAGE INFORMATION SUPPLEMENT Insurers, including self-insured employers, must submit this form with the first WKC-13 report for each claim where TTD is less than the maximum rate in the year the injury occurred. Read instructions on reverse carefully before completing. Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. Date of Injury Employee Social Security Number Employee Name Employer Name Name of Insurance Company or Self-Insured Employer (do not list adjusting company) Claims Handling Address (number, city, state, zip code) Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Imaging Server Fax: (608) 260-2503 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.wisconsin/wc e-mail: DWDDWC@dwd.wisconsin.gov Complete Section 4 for part-time employees (include anyone working less than 35 hours per week) before completing Sections 1 and 2.) 1. Hourly Wage Multiply Equals Add Equals a. Hourly rate at time of injury: Standard Base $ Piece Rate (if higher than the standard rate) Standard base rate plus tips Tip Rate only: $ Base + Tip $ x b. Hours per week: ( fill in "usual scheduled hours," check the box you = use to set the wages) Normal scheduled hours: Includes those hours paid at time-anda-half: (See Instructions) Actually Worked: (use with piece rate, or tips in Section 1a.) Expand to: (See Section 4) 24 Expand to Normal Full-time: Seasonal: (See instructions) 44 c. Base weekly rate: (See reverse for computing rates for time and a half employees) d. Additional weekly + = compensation from Section 3 below: (exclude tips) e. Average weekly earnings: (hourly) 2. Gross Wage Divide Equals Add Equals b. Number of weeks c. Base Gross d. Additional weekly e. Actual average a. Gross taxable wages in 52worked in 52-week Wage: compensation from week period prior to date of ÷ = = $weekly earnings: period prior to injury: Section 3 below: injury: (Exclude tips) $ $ $ 3. Additions to Cash Wage Received by Employee Per Week ( Mark any that apply) Free meals (Number/week) Weekly Amount $ Room (Number of days/wk Weekly Amount $ Tips Amount/Week $ (Add only to Section 2d., not 1d.) House or Apartment Weekly Amt $ Check if this is continued during disability Fuel Weekly Amount Lights Weekly Amount Other Weekly Amount Total Weekly Value: $ $ $ $ $ $ $ 4. Part-Time Employment (Worked less than 35 hrs/wk ) Part of Class Determination 1. Normal number of hours scheduled per week: 2. Number of other parttime employees doing same work on same schedule: Divide Equals 3. Number of full-time employees doing the same type of work: ÷ = 4. % by 3 is greater than 10%) Yes, part of class (2 divided No, not part of class (2 divided by 3 is less than 10%) (Choose a, b or c that applies) Employee worked less than 24 hrs/wk, is part of a class and does not restrict availability for work. Check the box listed as "expand to" in Section 1b above with number of scheduled hours shown as 24. b Employee worked less than 35 hours/wk, but is not part of a class and does not restrict availability for work. Check the box in Section 1b listed as "Expand to Normal full-time" and enter the number of hours which full-time employees normally work for the employer in this occupation. c Employee works less than 27 hrs/wk., and restricts availability for work. Check the box in Section 1b listed as "Normal Scheduled Hours" and enter the number of normal scheduled hours. If the employee does not have "normal scheduled hours", leave Section 1b blank and complete all parts of Sections 2 and 5 using the 100% option of the result in Section 2e in Section 5b. Attach the self-restriction statement. See instructions on reverse for an exception to using 100% in Section 5b. Important: These options are the only circumstances for which you will use a number other than the "normal hours scheduled" to compute weekly hourly wages. Use normal hours scheduled or actual hours worked (piece rate, time and 1/2 or tip rate) in Section 1b unless 4a, 4b or 4c applies. a 5. Weekly Wage and TTD Rate Computation a. Weekly Wage (Greater of #1 or #2 above) $ Insurance Claim Representative WKC-13-A (R. 08/2009) Multiply Equals x b. 66.67% OR 100%(see 4.c) Telephone Number = c. Weekly TTD Rate: $ ( ) (See reverse side for instructions) American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Wage Information Supplement, Form WKC-13-A These instructions will help you complete the WKC-13-A and compute the TTD rate correctly. If more help is needed, please contact a wage specialist at (608) 266-3264 or 261-6532, or send an e-mail to wcwage@dwd.state.wi.us. Section DWD 80.02(2)(c) of the Wis. Admin. Code requires insurers, including self-insured employers, to submit this form within 30 days after the injury. It must be submitted for every claim where the TTD rate is less than the maximum rate for the year the injury occurred. For a reference to the maximum rates, see our website at: http://www.dwd.state.wi.us/wc_train Section 1a- Hourly Rate at Time of Injury: Enter the standard base rate at the time of injury. Include in the hourly rate any additional hourly amounts which the employee received at the time of injury, e.g., shift differentials. For employees receiving time-and-a-half, enter the standard base rate, not time and a half rate. If this employee did not have an hourly rate but had a weekly, bi-weekly or monthly salary and has scheduled hours of work, divide the salary by the number of hours worked in the pay period to arrive at the hourly rate. If an employee is paid solely by commission or by mileage or some other method where scheduled hours are not used, the TTD rate will be based only on gross earnings. In such a case, enter "NA" in Section 1 and go on to Section 2. For employees paid on a piece work basis, compute the hourly piece work rate by dividing the earnings from piece work by the number of hours actually worked while on piece rate. Exclude time and a half earnings and hours in this computation. Use the piece rate amount only if the resulting rate is higher than the standard hourly rate. If the employee received tips, compute the additional hourly amount of tips. Enter that amount next to "tip rate" and add the hourly tip rate to the
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