Fill and Sign the Rhode Island Wage 497325278 Form

Week No. Week ending date No. standard hrs. worked Gross Wages 01                  02                   03                   04                   05                   06                   07                   08                   09                   10                   11                   12                   13                   14                   Week No. Week ending date No. standard hrs. worked Gross Wages                   16                   17                   18                   19                   20                   21                   22                   23                   24                   25                   26                                                                                                                          DWC No:       Insurer's No:       M F       Name       Address       Insurance Co.       Adjusting Co.             Hired for              Are these supplemental wages?       Maximum no. of exemptions       EMPLOYED FOR LESS THAN 2 WEEKS: Did you agree to pay the employee a certain hourly wage? 1. List agreed upon hourly wage       2. No. of hrs per week for full-time employees       employment.       3. Multiply #1 by #2 for average weekly wage             number of weeks employed up to 52                  number of weeks employed up to 52            TOTAL 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      - - / / ( ) - / / / / / / / / / / age Statement Overtime is included for incapacities on or after July 3, 1998, only. Part-Time Employment (less than 20 hours per week) State of Rhode Island Department of Labor and Training Division of Injured Workers' Services 610 Manton Avenue, P.O. Box 3500 Providence, RI 02909-0500 Phone: (401) 457-1800 TDD: (401) 457-1888 EMPLOYEE INFORMATION: CLAIM INFORMATION: Soc. Sec. No Employer City, State, Zip Injury date Phone Date of birth Incapacity date hours each week ( Approximate) Yes No Date Employed if yes, name of supplemental employer ____Single____Married Yes No If Yes: If No: Give the average weekly wage for same or similar OR LONGER. List gross wage prior to incapacity date, not prior to injury date. Use week EMPLOYED FOR 2 WEEKS of incapacity or week of hire only if a full week was worked. EXCLUDE OVERTIME AND BONUS MONIES IN WEEKLY BREAKDOWN. SEE BELOW LEFT CORNER FOR CALCULATION List 13 consecutive weeks. 15Total BONUS monies paid to employee in past 52 weeks Divided by number of weeks employed up to 52 equals * Total OVERTIME monies paid to employee in past 52 weeks Divided by number of weeks employed up to 52 equals ** I CERTIFY THAT I HAVE FOLLOWED THE OVERTIME PROVISIONS OF THE WORKERS' COMPENSATION ACT. EMPLOYER'S SIGNATURE DWC-03P (8/98) DATE INSURER'S SIGNATURE DATE