Workers’ Compensation Wage Statement Form
Employee Information
Employee Name
Employee ID/SSN
Job Title
Department
Date of Injury
Claim Number
Employer Information
Employer Name
Employer Contact
Employer Address
Wage Statement
Period Covered From
To
Pay Period Start
Pay Period End
Gross Wages
Hours Worked
Other Compensation
Explanation of Other Compensation (bonuses, overtime, etc.)
Additional Notes
Prepared By (Print Name)
Date
Signature