Wage Statement Immediately Preceding Injury Date {AR-W}

Form AR -W Authority: Ark. Code Ann. §11-9-518 Revised: 1-1-2001 ARKANSAS WORKERS' COMPENSATION COMMISSION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 W WAGE STATEMENT IMMEDIATELY PRECEDING INJURY DATE Weeks Straight Time Worked Days 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 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 Total American LegalNet, Inc. www.FormsWorkFlow.com Wages Paid For Straight Time Overtime Hours Worked Days Hours Wages Paid for Overtine AWCC No. Hours Carrier Claim No. Employee Name: Employee S.S.No.: Employer Name: Employer FEIN No.: Carrier or Self-Insured Name: Carrier NAIC No.: INSTRUCTIONS FOR COMPLETING WAGE STATEMENT (To be completed only if claimant receives less than maximum b enefits) In completing the W age Statement, in week one give information for the week pr ior to the injury and follow with preceding w eeks. Days and hours of straight time wor k should be given in all cases. Explanation of time lost by employee: w AWCC Form W (Wage Statemen t) 1. The AWC C Advisory 88-1 requires respondents to file Form W (w ith t he A WCC file number for the case, obtained from AWCC Form A-110) if the claimant receives less than the maximum compensation rate. 2. The average weekly wage of the injured worker shall "[I]n no case...be computed on less than a full-time workweek in the em ployment." [Ark . Code An n. § 11-9-518(a)(1)] Informa tion on F orm W is availab le from th e Office S ervices Se ction. Ge neral Info rmation is available from the Support Services Division. (1-800-622-4472 or 501-682-3930) Ark. Code Ann. §11-9-106(a): "Any person or entity who willfully and knowingly makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who willfully and knowingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers' compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and collected under .... this section shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trust Fund administered by the Workers' Compensation Commission." American LegalNet, Inc. www.FormsWorkFlow.com