Wage Statement
Claims Processing: Instructions Page
Fill this form for all employees which are scheduled to be on compensation. If compensation period is longer than one month, fill this form and print it for each of the months separately.
Accident date:
Claim Number:
Employee Name:
Employee Occupation:
Employer:
Average hours per week:
Wage per hour:
Select the dates which employees are scheduled to be on compensation. After printing the completed form, fill-in employees names in the correct boxes.
Select a month
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Name:
Signature:
Today's date:
Signed by:
Official position:
Claims Processing: Instructions Page