Injured Worker Earnings Statement {Wages-IW}

Wages-IW - INJURED WORKER EARNINGS STATEMENT. This form is used by the Bureau of Workers' Compensation (BWC) in Ohio for injured workers to report their employment history and earnings information for the 52 weeks prior to the date of injury or date of disability in an occupational disease claim. The form includes sections for the injured worker's personal information, details of each employer, self-employment information (if applicable), periods without earnings, and permissions for BWC to contact employers for clarification. The form also includes statements regarding the consequences of providing false information and a declaration of the injured worker's understanding of the compensation calculation process. The completed form is faxed or mailed to the BWC for processing. www.FormsWorkFlow.com