Fill and Sign the Wage Schedule New Hampshire Form

THIS WAGE SCHEDULE IS FOR 26 WEEKS PRIOR TO DATE OF INJURY AND MUST BE FILED WITH DEPART- MENT OF LABOR BY INSURANCE CARRIER TOGETHER WITH 9 WCA 4 . 5 . 6 . 7 . 8 . 9 . 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 Employee Wages per hour Avg- wkly. earnings Employer Address Carrier Name Address THE STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR CONCORD, N.H. 03301 WAGE SCHEDULE (NAME ) EMPLOYER MUST FORWARD TO INSUR- ANCE CARRIER BOTH COPIES OF Date of hire SCHEDULE AND CARRIER'S COPY OF SUPPLEMENTAL REPORT FORM NO. 13 WCA NO LATER THAN EMPLOYEE'S (NAME ) TEENTH DAY OF DISABILITY RESULTING FROM INDUSTRIAL ACCIDENT. (No. ) (Street) (city-State) Week Ending 1 2 3 GROSS EARNIINGS OTHER ADVANTAGES (See Wages Definition) TOTAL WAG ES: In addition to money pay- ments, means reason- able value of board, rent, housing, lodging, fuel or similar advantage re- ceived from the em. ployer, and gratuities received in the course of employment from others, but not including any sum paid by the em- ployer to cover any spe. cial expenses entailed on the employee by the na. lure of his employment. Please provide a brief explanation for weeks with no wages. RSA 281-A:2, Par. XV. (Employer's Signature) (Titl e) Dept. Approval Dat e 76 WCA (I 2- 90) White - Labor Dept. (Mail to Carrier) Canary - insurance Carrier (Mail to Carrier)