How to get a wage statement from an employer for a workers comp claim, for claims assistants?

Send the state’s wage statement form, or the carrier’s wage form if the state has none, to the employer’s payroll or HR desk with the claim number, date of injury, and a return fax or portal. A complete statement covers the average weekly wage period that state uses, with gross wages, hours, overtime, and non-cash pay.

This is for the claims assistant, case coordinator or medical-only examiner at a regional TPA, self-insured desk or carrier unit who works lost-time files in Guidewire, Origami Risk, mySedgwick, Juris or a spreadsheet of outstanding items.

A wage statement is the employer’s written report of pre-injury earnings. The adjuster uses it to set average weekly wage (AWW) and the indemnity rate. It is not a pay stub, not the first report of injury, and not a medical record. The counterparty is payroll, not the clinic. Rules vary by state. The rows below are only the statutes, rules and forms read for this page. Check the state’s division and counsel. This is not legal advice.

What a complete wage statement contains

A complete statement is the state’s numbered form, or the carrier’s wage form where the state has no number, covering the AWW period that state uses.

Item	Why it is on the statement
Injured worker name, claim number, date of injury	Wrong person or wrong DOI puts AWW on the wrong weeks
Date of hire and employment status	Full-time, part-time, seasonal or similar-employee rows change the math
Gross wages for the state’s AWW period	Texas and Florida use 13 weeks before the injury. New York uses 52
Hours or days worked in each period	Needed for a short week, or when a similar employee is substituted
Overtime, bonuses, commissions, tips reported as taxable	Base hourly rate alone understates AWW on most lost-time files
Non-cash pay, or a yes/no that none was paid	Health insurance, housing, meals, a vehicle. A blank is incomplete in Texas
Whether those non-cash items continue after the injury	If they continue, they usually stay out of AWW

Texas DWC Form-003 (Rev. 10/22, read 2026-10-09), Florida DFS-F2-DWC-1a (Rule 69L-3.025, F.A.C., read 2026-10-09) and New York Form C-240 (read 2026-10-09) are the numbered packets. Other states use a carrier form. Ask payroll to complete the form the file needs, not a generic earnings letter.

What to put in the request

Where a statute or form starts a clock, it runs from a complete request to the desk that has the wages.

Item	Why it is on the request
The state’s form, or the carrier’s wage form, blank and attached	Payroll will not hunt the form
Claim number, injured worker name as on payroll, date of injury	Match to the right employee
The AWW period to report	13 weeks before DOI in Texas and Florida. 52 weeks in New York. Skip the week of the accident on a Florida DWC-1a
Where to send it	The fax, email or portal already on the file for that employer
Claims assistant name, callback number, and the diary date	So the completed form lands on this file

Send it on the employer business line, payroll fax or the email already on the claim. Do not autodial the injured worker’s cell for this packet.

What to leave off

Item	Why it delays or fails
Request to the first-report or plant contact only	That person rarely has 13 or 52 weeks of gross wages
“Please send pay stubs” with no form	Stubs are backup. They are not the wage statement
Wages after the date of injury in the AWW period	Texas DWC flags post-injury amounts on DWC Form-003 as a usual AWW error
A verbal figure from HR treated as the statement	File note, not a form the adjuster can defend
Combining two employees on one form	Florida’s DWC-1a instructions say do not combine wages of two or more employees

Who has the wages, and how to chase

Payroll or HR holds the ledger. The plant manager who reported the injury usually does not. On r/WorkersComp in August 2025, a commenter wrote that the desk has no access to the employer’s payroll system, so the employer has to submit it, and some take a while if they ever do it at all. Some TPA desks already have a payroll feed. Treat payroll as the counterparty unless this employer already shares one.

1. Pull the outstanding wage-statement row from Guidewire, Origami, mySedgwick, Juris or the spreadsheet.
2. Find the payroll or HR number already on the file. If the only number is the first-report contact, ask that person for the payroll clerk by name.
3. Send the complete request on that channel. Log the sent date, number or address, and who took it.
4. If nothing is back in three business days, call the same payroll clerk. Do not open a second request to a new inbox.
5. When the indemnity diary is inside 14 days, escalate to the employer’s workers’ compensation coordinator. A Texas DWC request then starts a seven-day clock under 28 TAC §120.4(a)(3). A New York Board request starts a ten-day clock.

State clocks we read

Only states whose rule or form we read. Other states differ.

Place	Form	AWW period	When the employer has to file
Texas	DWC Form-003	13 weeks before DOI (14 if biweekly, three months if monthly)	Labor Code §408.063(b) says 30 days after notice of injury. The Form-003 FAQ and 28 TAC §120.4 time it from notice of income-benefit entitlement, or a compensable death, and within seven days of a DWC request. Use the form’s clock. Check counsel.
Florida	DFS-F2-DWC-1a	13 Sunday-Saturday weeks before the accident week. Skip the accident week.	The form (Rule 69L-3.025, F.A.C.) says file with the claims-handling entity within 14 days after knowledge of an accident that caused disability for more than 7 calendar days. §440.14(4) adds a corrected statement within 7 days if fringes stop.
New York	C-240 / EC-240	52 weeks of gross weekly earnings before DOI, with paid time off in “days paid”	Subject Number 046-949 (June 19, 2017, read 2026-10-09) requires C-240 within 10 days of the Board’s request. The online form is electronic only.

If the injured worker was not employed for the full AWW period, Texas and Florida want a similar employee’s wages, not a short history padded with zeros. New York wants a worker of the same class when the injured worker did not work a substantial part of the year. The Board’s guideline is 234 days on a five-day week or 270 on a six-day week, not a hard cutoff.

When the packet comes back incomplete

TDI’s common-mistakes sheet on death-benefit AWW (read 2026-10-09) is the Texas checklist. The same holes show up on Florida and New York files.

What landed	Why it is not done	What to do
Pay stubs, no form	Stubs are not the statement	Resend the form. Keep the stubs as backup
Form with nonpecuniary Part 2 blank	Incomplete under 28 TAC §120.4	Return it. Yes or no is required
Thirteen weeks that include days after DOI	Post-injury wages on the AWW period	Ask payroll to recut the dates
New hire, no similar employee	Wrong method	Ask for a comparable worker’s wages
Hourly rate times 40, no actual hours	Estimate, not the statement	Pay the estimate where the state allows it. Keep the form outstanding
Oral figure from HR	Not a filing	Get the signed form on a logged channel

On a Texas file, 28 TAC §128.2 (compiled rules updated 2026-01-06, read 2026-10-09) tells the carrier to presume hourly rate times usual hours, or the last full-week paycheck, until a complete wage statement is in, then recalculate. An estimate starts benefits. It does not close the outstanding item.

Concurrent jobs and similar employees

A second job is not this chase. Texas DWC Form-003ME (Rev. 05/23, read 2026-10-09) is the injured employee’s multiple-employment statement. Florida §440.14(5) puts concurrent wage loss on the employee. Chase the claim employer’s statement on its own diary.

A similar employee has comparable training, experience, skills, pay and hours. Florida’s DWC-1a uses one if the injured worker was not employed about 68 days of the 13 weeks. Do not combine two people onto one row.

Pull the open lost-time claims with a wage-statement row still outstanding and a clock in the next 14 days. Confirm each has the state’s form, or the carrier form, sent to payroll rather than the first-report contact, with the claim number, date of injury and a return fax. Resend any packet that is a pay-stub stack or a blank nonpecuniary section, and log the sent date on the file that afternoon.