Fill and Sign the Rhode Island Wage Form

Week No. Week ending date No. standard hrs. worked Gross Wages 01                  02                   03                   04                   05                   06                   07                   Week No. Week ending date No. standard hrs. worked Gross Wages 08                   09                   10                   11                   12                   13                   DWC No:       Insurer's No:       Soc. Sec. No             Name       Address       City, State, Zip       Insurance Co.       Adjusting Co.       Injury date       Phone       Date of birth       Incapacity date       Date Employed       Hired for             Are these supplemental wages?          Maximum no. of exemptions       1. List agreed upon hourly wage             employment.       3. Multiply # 1 by # 2 for average weekly wage                         Total OVERTIME monies paid to employee in past 52 weeks       Divided by number of weeks employed up to 52 equals       TOTAL of 13-wks EARNINGS       Number of usable weeks recorded       Divide total earnings by number of usable weeks       Add average BONUS* for pre-injury AWW excluding OVERTIME       Then add average OVERTIME** for AWW used to determine weekly Compensation Rate                               Wage Statement Overtime is included for incapacities on or after July 3, 1998, only. Full-Time Employment {20 hours or more per week} State of Rhode Island Department of Labor and Training Division of Workers' Compensation P.O. Box 20190 Cranston, RI 02920-0942 Phone: (401) 462-8100 TDD: (401) 462-8084 EMPLOYEE INFORMATION: CLAIM INFORMATION: M F Employer hours each week ( _ Approximate) Yes No If yes, name of supplemental employer Single EMPLOYED FOR LESS THAN 2 WEEKS: Did you agree to pay the employee a certain hourly wage? Yes No If Yes: If No: Give the average weekly wage for same or similar 2. No. of hrs per week for full-time employees EMPLOYED FOR 2 WEEKS OR LONGER. List gross wage prior to incapacity date, not prior to injury date. Use week of incapacity or week of hire only if a full week was worked. EXCLUDE OVERTIME AND BONUS MONIES IN WEEKLY BREAKDOWN. USE THE OVERTIME/BONUS BLOCK BELOW. List 13 CONSECUTIVE weeks. Total BONUS monies paid to employee in past 52 weeks Divided by number of weeks employed up to 52 equalsWEEKS EMPLOYED * ** I CERTIFY THAT I HAVE FOLLOWED THE OVERTIME PROVISIONS OF THE WORKERS' COMPENSATION ACT. Employer Signature DWC-03F (06/00) Date Insurer Signature Date