Employer Report Of Employee Earnings For Wage Loss Compensation {BWC-1269}

BWC- 1269 -- EMPLOYER REPORT OF EMPLOYEE EARNINGS FOR WAGE LOSS COMPENSATION. This form is used for reporting employee earnings for the purpose of wage loss compensation in the context of workers' compensation. It includes sections to be completed by both the injured worker and the employer. The injured worker provides details such as dates of injury, requested wage loss benefits period, and consent for BWC to contact the employer for clarification on reported earnings. The employer provides information on gross earnings for the injured worker during specific pay periods, including any additional payments like bonuses or commissions. If you are submitting copies of payroll check stubs or other proof of earnings provided to you by your current employer, then do not complete this form. If you are not submitting copies of payroll check stubs or other proof of earnings, complete this form for submission of earnings for the payment of wage loss compensation. www.FormsWorkflow.com