What should a workers comp wage statement include, for claims assistants?

A complete workers comp wage statement includes the state’s numbered form, or the carrier’s wage form if the state has none, covering the average weekly wage period that state uses, with gross wages, hours or days worked, overtime, and a yes or no on non-cash pay. Pay stubs are backup. They are not the statement.

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 a W-2, and not the California Labor Code 226 itemization payroll already prints. How to get a wage statement from an employer is the first request. What to do when the employer won’t send one is the silent file. This page is the completeness check. Rules vary. Check the state’s division and counsel. This is not legal advice.

What belongs on the statement

A complete statement is the state’s numbered form, or the carrier’s wage form where the state has no number.

Item	Why it belongs
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. Gross, not take-home
Hours or days worked in each period	Needed for a short week, or when a similar employee is substituted
Overtime, bonuses, commissions, taxable tips	Base hourly rate alone understates AWW on most lost-time files
Non-cash pay, or a yes or 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
Name of the person who filled it out, and a certification	Texas 28 TAC §120.4(c) (compiled rules updated 2026-09-28, read 2026-10-09) requires both

On r/WorkersComp in August 2025 a commenter wrote that take-home is irrelevant to workers’ compensation math, and that the file needs gross pay. Net pay or a rate letter leaves the outstanding item open.

Texas splits money and non-cash. 28 TAC §126.1 (read 2026-10-09) puts hourly pay, salary, piecework, bonuses, commissions and cash allowances in pecuniary wages, and health insurance, laundry, uniforms, lodging, meals, a vehicle or fuel, and professional license fees in nonpecuniary wages. DWC Form-003 (Rev. 10/22, read 2026-10-09) puts cash in Part 1 (stipends in box 20) and non-cash in Part 2, with a yes or no on each column. §128.1(d) uses gross. Mileage, helper pay and travel reimbursement stay out.

Florida’s DWC-1a (03/2009, Rule 69L-3.025, F.A.C., read 2026-10-09) is narrower on fringes: gratuities only if reported in writing as taxable, plus employer-cost health insurance and year-round housing. New York C-240 (read 2026-10-09) asks for board, rent, housing, tips and gratuities as a weekly value, and says other earnings do not include accrued unused vacation.

What to leave off

Item	Why it fails
Pay stubs, a W-2, or a payroll export with no form	Stubs are backup. They are not the statement
Net or take-home pay	AWW is gross. New York C-240 says do not use take-home
Wages after the date of injury in the AWW period	TDI’s common-mistakes sheet (read 2026-10-09) flags post-injury amounts on DWC Form-003
The week of the accident on a Florida grid	DWC-1a skips the accident week. Use the 13 Sunday-Saturday weeks before it
Combined wages of two employees	Florida’s DWC-1a instructions say do not combine
An oral figure from HR, logged as a file note	Not a filing the adjuster can defend
Concurrent-employer wages on the claim employer’s form	Separate packet. Texas DWC Form-003ME. Florida puts concurrent wage loss on the employee

Fields on the numbered forms we read

Only states whose form we read. Other states use a carrier form. Ask payroll to complete the form the file needs.

Place	Form	AWW period on the form	What the form also asks
Texas	DWC Form-003 (Rev. 10/22)	13 weeks before DOI (14 if biweekly, three months if monthly), hours and gross per period	Employment status. Pecuniary Part 1 and nonpecuniary Part 2, yes or no on each benefit, and whether it continued after DOI. Signature.
Florida	DFS-F2-DWC-1a	13 Sunday-Saturday weeks before the accident. Skip the accident week.	Customary days and hours. Gross, taxable gratuities, employer-cost health insurance and rent/housing, and whether those continue. Similar-employee yes/no.
New York	C-240 / EC-240	52 weeks of gross weekly earnings before DOI, days paid including paid time off	Pay-rate basis, days-per-week, board/rent/tips, wage adjustments and layoffs. Same-class grid if the worker did not work a substantial part of the year. Electronic only.

28 TAC §120.4(c) lists the Texas minimum: employee name, address, social security number, date of hire, date of injury, employer name, address, federal tax ID, employment status, the person submitting the report, the 13-week wage and hours, and a certification that the wage information is complete and accurate.

Florida §440.14 (2026 Florida Statutes, read 2026-10-09) sets AWW as one-thirteenth of wages in the 13 calendar weeks before the accident week when the employee worked substantially the whole of those weeks, meaning not less than 75 percent of customary full-time hours. New York Subject Number 046-949 (June 19, 2017, read 2026-10-09) requires C-240 within 10 days of the Board’s request.

How to tell the packet is complete

TDI’s common-mistakes sheet on death-benefit AWW 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
Florida grid that starts with the accident week	Wrong 13 weeks	Recut to the 13 Sunday-Saturday weeks before the accident week
New hire, zeros padded to 13 or 52	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. Keep the form outstanding
NY C-240 with days worked but no days paid	Board wants days compensated, including PTO	Ask payroll to recut the days-paid column

On a Texas file, 28 TAC §128.2 (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, similar employees, and continued fringes

A second job is not this form. 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. 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. Do not combine two people onto one row.

Non-cash pay that continues after the injury usually stays out of AWW while it continues. Texas 28 TAC §128.1(c)(2) keeps continued nonpecuniary wages out, then puts them back in when the employer stops them. Florida §440.14(2) deducts board, rent, housing or lodging the employer keeps providing. Florida §440.14(4) requires a corrected DWC-1a within 7 days if those fringes stop. That corrected statement is a new packet, not a diary note.

Pull the open lost-time claims that already have a wage packet in the file. Check each form against the state’s AWW period, hours, gross pay, overtime, and the non-cash yes-or-no. Return any stub stack, blank nonpecuniary section, or grid that includes days after the date of injury, and log the sent date that afternoon.