Fill and Sign the Statement of Weekly Earningsdoc Form

STATEMENT OF WEEKLY EARNINGS If the actual payroll records reflect the format below, a printout of the records can be attached. If not, please complete this form. INSTRUCTIONS: 1. Give employee’s regular weekly earnings and overtime hours in separate columns for the 52 weeks prior to the date of injury. Do not include any sums paid the employee for expenses due to the special nature of his/her employment. Whatever allowances specified as a part of the wage contract in lieu of wages shall be deemed a part of the employee’s earnings. 2. If the above information cannot be given, show: … Weekly earnings of employee for the length of time he/she has been in your employ. … Weekly earnings of a similar worker in the same class of work either in your employ or in the same locality for same period as checked in item (1) above. 3. If above information cannot be given show weekly earnings for any employee who has worked during the same period checked above. 4. How many days constitute your normal work week?___________ How many hours?________ 5. Give hourly rate ________________ Weekly rate ___________________ 6. If the employee was not paid on a weekly basis, explain fully give his/her earnings for the period checked above. __________________________________________________________________________ __________________________________________________________________________ Week No. Week From To Number of days worked Amount paid exclusive of overtime Overtime hours worked or OT earnings Date Date 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 . Totals Carried forward Week No. Week From To Number of days worked Amount paid exclusive of overtime Overtime hours worked or OT earnings Date Date Brought forward 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 Totals