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EMPLOYER'S STATEMENT OF WAGE EARNINGS

C-240 (6-17) EMPLOYER'S STATEMENT OF WAGE EARNINGS ( preceding the Date of Injury/Illness)Claim Information - ALL COMMUNICATION SHOULD INCLUDE THESE NUMBERSWCB Case #:Claim Administrator Claim (Carrier Case) #:Date of Injury/Illness:Injured Worker InformationFirst Name:Last Name:MI:Mailing Address:Line 2:City:State:Zip Code:Job Title:Social Security #:Insurer InformationInsurer Name:Insurer ID (W#):Mailing Address:Line 2:City:State:Zip Code:Insurer Phone #:Insurer Fax #:Email Address:Employer InformationEmployer Name:Mailing Address:Line 2:City:State:Zip Code:SSNEINF ederal Tax ID #:The Tax ID # is the (check one):Employer Phone #:To determine Average Weekly Wage, the Board needs the gross weekly EARNINGS for the 52 weekly periods immediately preceding the date of the injury/illness.

C-240 (6-17) Page . www.wcb.ny.gov. EMPLOYER'S STATEMENT OF WAGE EARNINGS (Preceding the Date of Injury/Illness) Claim Information - ALL COMMUNICATION SHOULD INCLUDE THESE NUMBERS

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