Seasonal Wage Statement {DWC-03S}

State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORT SEASONAL WAGE STATEMENT (Hired for 16 weeks or less) Department of Labor and Training, Division of Workers' Compensation DWC No. PO Box 20190, Cranston, RI 02920-0942 1. EMPLOYEE INFORMATION: SSN Name Maximum no. of exemptions________ Single Married Phone (401) 462-8100 TDD (401) 462-8006 Insurer File No. 2. CLAIM INFORMATION: Employer Insurance Co. Claim Administrator Injury date Incapacity date Hire date Wages for how many employers are listed below? List 52 CONSECUTIVE weeks of gross wages for any employment held by this person within the 52 week period. Week Number Week Ending Date Gross Wages Week Number Week Ending Date Gross Wages 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Total earnings: 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Total earnings: 1. Combine total earnings listed 2. Divide total earnings by 52 3. Average Weekly Wage $ Date: ÷ 52 Print Preparer Name: Date: Print Adjuster Name: DWC-03S (01/03) For instructions visit our web site: www.dlt.ri.gov/wc American LegalNet, Inc. www.FormsWorkFlow.com