Fill and Sign the Form Wc 5 Download Printable PDF Employees Claim for

Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (3 pages including instruction sheet) (Rev. 1 /18) STATE OF HAWAI I DEPARTMENT OF LABOR AND INDUSTRIAL RELAT IONS DISA BILITY COMPENSA TION DIVIS ION Pr ince ss Keel ikolan i Buil ding, 830 Punchbowl Street, Room 209, Honol ulu, Ha wa ii 96813 INSTRUCTION SHEET FOR FORM W C-14 EM PLOYEE'S W AGE-REPORT FOR FIFTY-TWO WEEKS Instructi ons Please compl etely fill out the WC-14 EMPLO YEE' S WAGE-REPORT FOR FIFTY-TWO WEEKS FORM. The De livery In formation section below lists various delivery options. Please select the most convenient method and submit the completed form accordingly. Please rem ember to si gn and date the form before submi tting it. Delivery Informat ion Deli very by U.S. Ma il Department of Labor and Industrial Relations , Disability Compensation Division P.O. Box 3769, Honolulu, Hawaii 96812-3769 Deli very In-P erso n Department of Labor and Industrial Relations, Disability Compensation Division Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813 Deli very vi a Fax Department of Labor and Industrial Relations, Disability Compensation Division (808) 586-9219 Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (3 pages including instruction sheet) (Rev. 1 /18) STATE OF HAWAI I DEPARTMENT OF LABOR AND INDUSTRIAL RELAT IONS DISA BILITY COMPENSA TION DIVIS ION Pr ince ss Keel ikolan i Buil ding, 830 Punchbowl Street, Room 209, Honol ulu, Ha wa ii 96813 FORM W C-14 EMPLOYEE' S WAG E-R EPORT FOR FIFTY-TWO WEEKS EMPLOYEE'S WAGE-RE PORT FOR F IFTY-TWO WEEKS PRIOR TO DATE OF INJURY Employee: SS No.: Case No.: - - Date of Injury: The above employee reported employment with your firm U nder the Hawaii Workers' Compensation Law; an employee's benefits are calculated based on wages earned. Please assist us in determining benefits by completing this form Employer: Employee's Occupation: Hourly Rate: Date Employed: Presently Employed? If terminated, date: Disabled from: through: Returned to Work: Indicate the days and hours normally worked: Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: If other than the above, please indicate: Please call Records and Claims Branch at 586-91 61 if you have Questions Employer:Telephone: ( ) Address Date: By: (To be signed in ink) Auxiliary aids and services are availabl e upon request. Please call : (808) 586-91 61; TTY (808) 586-8847; and for neighbor islands, TTY 1-888-569-6859. A request for reaso nable accommodation(s) should be made no later than ten working da ys prior to the needed accommodation(s). It is the policy of the Department of Labor and Industrial Relations that no person shall, on the basis of race, color, sex, marital status, religion, creed, ethnic origin, national origin, age, disability, ancestry, arrest/c ourt record, sexual orienta tion, and National Guard participation, be subjected to discriminati on, excluded from participati on in, or denied the benefits of the Department’s servic es, progra ms, activities, or employment. Employee: SS No.: Case No.: - - Date of Injury: Dates (inclusive) of each period paid for Dates (inclusive) of each period paid for From To Year Hours, Days, Weeks or month each Payment Covers Total amount paid Employee for each period Amount paid excluding overtime or extra work Overtime or extra work From To Year Hours, Days, Weeks or month each Payment Covers Total amount paid Employee for each period Amount paid excluding overtime or extra work Overtime or extra work 1 27 228 329 430 531 632 733 834 935 1036 1137 1238 1339 1440 1541 1642 1743 1844 1945 2046 2147 2248 2349 2450 2551 2652 Total Total This statement of Employee's earnings is taken from our Payroll Records. This statement of Employee's earnings is taken from our Payroll Records.