Transcription of EMPLOYER'S STATEMENT OF WAGE EARNINGS …
1 STATEOFNEWYORKWORKERS'COMPENSATIONBOARDE MPLOYER'SSTATEMENTOFWAGEEARNINGS(Precedi ngtheDateofAccident) ' ' "Yes", :(Check"X"one) (hourly,daily,weeklyormonthly)(5,6or7) (234daysfora5dayweek,270daysfora6dayweek )givetheweeklygrossearningofanotheremplo yeeofthesameclasswhohasworkedforayearora substantialpartthereofimmediatelyprecedi ngthedateofaccident.(Nameofemployeeofthe sameclass)(Address)Week WorkedGrossamountpaidincludingovertimeWe ek WorkedGrossamountpaidincludingovertimeWe ek ,lodging,board,tips,bonusorotherallowanc einadditiontotheaboveearnings?..If"Yes", stateweeklyvaluethereof$..Describe:.. "Yes",explain.
2 (8-09) (8-09)ReverseALBANY12241-100 Broadway,Menands.(866)750-5157 Forallaccidentsinfollowingcounties:Alban y,Clinton,Columbia,Dutchess,Essex,Frankl in,Fulton,Greene,Hamilton,Montgomery,Ren sselaer,Saratoga,Schenectady,Schoharie,U lster,Warren, ,44 HawleyStreet.(866)802-3604 Forallaccidentsinfollowingcounties:Broom e,Chemung,Chenango,Cortland,Delaware,Ots ego,Schuyler,Sullivan,Tioga, 369 Franklin Street.(866)211-0645 Forallaccidentsinfollowingcounties:Catta raugus,Chautauqua,Erie, (866)211-0644 Forallaccidentsinfollowingcounties:Alleg any,Genesee,Livingston,Monroe,Ontario,Or leans,Seneca,Steuben,Wayne,Wyoming, (866)802-3730 Forallaccidentsinfollowingcounties:Cayug a,Herkimer,Jefferson,Lewis,Madison,Oneid a,Onondaga,Oswego, (forNewYorkCity,Hempstead,Hauppauge&Peek skilldistrictoffices)-POBox5205,Binghamt on, (800)877-1373 Hemp.
3 (866)805-3630 Haup.(866)681-5354 Peek.(866)746-0552 Forallaccidentsinfollowingcounties:Bronx ,Kings,Nassau,NewYork,Orange,Putnam,Quee ns,Richmond,Rockland,Suffolk, Fax Line: 877-533-0337
