Form Twcc 3 PDF Details

In order to ensure effective communication with our clients, TWCC has developed a customer service form for our clients to complete. This form will help us gather the necessary information to best serve our customers. The TWCC 3 form is designed to collect specific information about the nature of the inquiry, and to provide our staff with all of the necessary contact information in order to follow up on the inquiry. We appreciate our clients’ feedback and look forward to serving them in the best possible way. Thank you for your time and cooperation!

QuestionAnswer
Form NameForm Twcc 3
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesTWCC 3 twcc 3 form

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Send to workers’ compensation carrier:

(name and fax number of carrier)

TWCC #

CARRIER’S CLAIM #

Initial

Amended EMPLOYER’S WAGE STATEMENT

The Texas Workers' Compensation Act and Commission rules require an employer to provide an Employer's Wage Statement to its workers' compensation insurance carrier (carrier) and the claimant or the claimant’s representative, if any. The purpose of the form is to provide the employee's wage information to the carrier for calculating the employee's Average Weekly Wage (AWW) to establish benefits due to the employee or a beneficiary.

The AWW is based on the wages the employee earned in the 13 weeks immediately preceding the date of injury (or the wage a similar employee earned if the employee did not work the full 13-week period). "Wages" include all forms of remuneration payable to an employee for personal services, including fringe benefits. To simplify filing, employers may file wages in a monthly, biweekly, or weekly manner as discussed below.

NOTE - An employer who fails without good cause to timely file a complete wage statement as required by the Texas Workers' Compensation Act, Texas Labor Code, Section 408.063(c) and Commission Rule 120.4 may be assessed an administrative penalty not to exceed $500.00 for an initial offense and not to exceed $10,000.00 for a repeated administrative violation.

The employer shall timely file a complete wage statement in the form and manner prescribed by the Commission.

(1)The wage statement shall be filed (“filed” means received) with the carrier, the claimant, and the claimant's representative (if any) within 30 days of the earliest of:

(A)the employee’s eighth day of disability;

(B)the date the employer is notified that the employee is entitled to income benefits;

(C)the date of the employee’s death as a result of a compensable injury.

(2)The wage statement shall also be filed with the Commission within seven days of receiving a request from the Commission (Only When Requested).

(3)A subsequent wage statement shall be filed with the carrier, employee, and the employee’s representative (if any) within seven days if any information contained on the previous wage statement changes (such as if the employer discontinues providing a nonpecuniary wage that was initially continued after the date of injury).

All applicable TWCC rules can be found at www.twcc.state.tx.us

EMPLOYEE AND EMPLOYER INFORMATION

 

 

 

Employee’s Name (Last, First, M.I.):

 

Employer’s Business Name:

 

 

 

 

 

Employee’s Mailing Address (Street or P.O. Box):

Employer’s Mailing Address (Street or P.O. Box):

 

 

 

 

 

 

 

City:

State:

ZIP Code:

City:

State:

ZIP Code:

 

 

 

 

 

 

Social Security Number:

 

 

Federal Tax I.D. Number:

 

 

 

 

 

 

Date of Hire:

 

Date of Injury:

Name and Phone # of Person Providing Wage Information:

 

 

 

 

 

 

As of today’s date, the employee is not back at work. OR

The employee returned to work on ____________ and is working:

without restriction. OR

with restrictions and is earning wages of $_____________ per

week/month (circle one).

NOTE – Rule 120.3 requires the employer file the Supplemental Report of Injury (TWCC-6) to report changes in Work Status and Post-Injury Earnings.

I HEREBY CERTIFY THAT this wage statement is complete, accurate, and complies with the Texas Workers' Compensation Act and applicable rules, and the listed wages include all pecuniary and nonpecuniary wages paid for (earned in) the 13 weeks prior to the date of injury (as described on page 2) and I understand that making a misrepresentation about a workers’ compensation claim is a crime that can result in fines and/or imprisonment.

Signature: __________________________________ Date: ____________

EMPLOYMENT STATUS AT TIME OF INJURY (Check All That Apply)

 

 

 

Full-time: employee who regularly works at

 

 

 

Part-time: Regular Course of Conduct:

 

 

Minor: employee less than 18 years of age

 

 

 

 

 

 

 

 

 

least 30 hours per week and whose schedule is

 

 

employee whose work history for the 12-month

 

and not emancipated by marriage or judicial

 

comparable to other employees of the company

 

 

period preceding the injury shows the person only

 

action who is also an apprentice, trainee or

 

and/or other employees in the same business or

 

 

worked part-time during that period.

 

student.

 

 

vicinity who are considered full-time.

 

 

 

 

 

Part-time: Not Regular Course of Conduct:

 

 

Student:

employee enrolled in a course of

 

 

 

Seasonal: employee who as regular course of

 

 

employee

whose work

history for the 12-month

 

study in high school, college or other institute of

 

 

 

 

 

 

 

 

 

 

 

period preceding the injury shows part-time and full

 

higher education or technical training.

 

conduct engages in seasonal

or

cyclical

 

 

 

 

 

 

time work during that period.

 

 

 

 

 

employment that may or may not be agricultural in

 

 

 

 

 

 

 

 

 

 

Apprentice: employee who is learning a skilled

 

 

Trainee:

employee undergoing systematic

 

nature and that does not continue throughout the

 

 

 

 

 

 

 

 

trade or art by practical experience under the

 

instruction and practice in some art, trade or

 

year.

 

 

 

 

 

 

 

 

 

 

direction of a skilled crafts person or artisan.

 

profession with a view towards proficiency in it.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SAME OR SIMILAR EMPLOYEE?

 

 

 

 

 

If the employee was not employed for 13 continuous weeks before the date

 

The wage information on this form is for:

 

 

 

 

 

 

of injury, report the wages of an employee who has training, experience,

 

 

 

 

 

 

 

skills & wages comparable to the injured employee AND who performs

 

 

 

The Injured Employee OR

 

A

Similar

 

Employee

(NOTE – If

 

 

 

 

 

services/tasks comparable in nature and in number of hours. If no similar

 

 

 

 

 

requested by the Commission, the employer

shall identify

the similar

employee exists, report

the limited available wages earned by the

 

employee whose wages were provided.)

 

 

 

 

 

 

injured employee prior to the injury.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE TO INJURED EMPLOYEE – If you were injured on or after 7/1/02, and had employment with more than one employer on the date of injury, you can provide your insurance carrier with wage information from your other employment for the carrier to include in your AWW and this may affect your benefits. Contact your carrier for additional information or call the Commission at (800) 252-7031. You can also read rule 122.5 at www.twcc.state.tx.us.

TWCC-3 (Rev. 07/04) Page 1 of 2 *F3P1-0704*

TEXAS WORKERS’ COMPENSATION COMMISSION

WAGE INFORMATION INSTRUCTIONS

Employee Name:

Social Security #:

Date of Injury:

-The employer shall report all wages earned in the 13 weeks immediately preceding the date of injury. If the employee is paid on a monthly or semi-monthly basis, the employer may provide wages for the 3 months preceding the date of injury. Monthly wages may also be converted to weekly wages by dividing the gross monthly amount by 4.34821. If the employee is paid on a biweekly basis, the employer may provide the wages for the 14 weeks preceding the date of injury. When setting the periods to report, the employer may adjust the reporting period backward slightly (up to six days) to line up the reporting timeframes with the employer’s natural pay cycle. However, the employer shall not report wages earned on or after the date of injury.

-If reporting weekly earnings, use all 13 Period Columns below. If reporting 3 months of earnings, either convert the wages to weekly earnings or use the first 3 Period Columns. If reporting 14 weeks of biweekly earnings, use the first 7 Period Columns. In all cases, indicate the dates that each period covers.

 

 

 

 

 

 

 

 

 

 

 

 

Pecuniary Wages include all wages that are paid to the employee in the form of money. These include, but are not limited to:

 

 

 

 

 

 

 

 

 

 

 

 

hourly, weekly, biweekly, monthly, etc. wages; salary; tips/gratuities; piecework compensation; monetary allowances; bonuses; and

 

 

PECUNIARY WAGE INFORMATION

 

 

 

commissions.

Earnings are reported in the periods they are earned, NOT when they are paid and some (such as bonuses and

 

 

 

 

 

commissions) need to be prorated. Pecuniary wages don’t include payments made by an employer to reimburse the employee for the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use of the employee's equipment or for paying helpers or to reimburse for travel expenses. Consider as earnings amounts from paid

 

 

 

 

 

 

 

 

 

 

 

 

holidays and any vacation, personal or sick leave an employee used but not the market value of leave time earned but not used.

 

 

PERIOD # (Week #,

 

1

 

2

 

3

 

 

4

 

5

6

7

8

9

10

11

12

 

13

 

 

 

Month #, or Bi-Week #)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTALS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

# HOURS WORKED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GROSS WAGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EARNED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NONPECUNIARY WAGE INFORMATION

 

 

Nonpecuniary Wages include all wages paid to the employee in a form other than money. These include, but are not limited to, the

 

 

 

benefits listed below but do not include monetary allowances or stipends paid to allow the employee to purchase the benefits.

 

 

 

 

 

 

 

 

 

 

 

 

 

Nonpecuniary

Employer

 

Specify Value Or Amount Earned in Each Reported Period For Each Benefit Provided Prior To Injury

Will Employer

Date Benefit

 

 

Wage Type

Provided Prior

 

 

 

 

 

 

 

(Use the same periods as used above)

 

 

 

Continue To

Suspended

 

 

 

To Injury?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide?

(if suspended)

YES

NO

1

2

3

4

5

6

7

8

9

10

11

12

13

YES

NO

Health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Laundry/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cleaning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clothing/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Uniforms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lodging/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Housing/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Food/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fuel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TWCC-3 (Rev. 07/04) Page 2 of 2

 

 

 

*F3P2-0704*

 

 

 

TEXAS WORKERS’ COMPENSATION COMMISSION

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This PDF form will require specific information to be filled in, thus be sure to take whatever time to provide precisely what is asked:

1. The Form Twcc 3 will require certain information to be typed in. Be sure the following blanks are completed:

Form Twcc 3 conclusion process outlined (portion 1)

2. After the previous part is complete, you should include the essential details in EMPLOYEE AND EMPLOYER INFORMATION, Employers Business Name, Employees Mailing Address Street, Employers Mailing Address Street, City State ZIP Code, City State ZIP Code, Social Security Number, Federal Tax ID Number, Date of Hire, Date of Injury, Name and Phone of Person, As of todays date the employee is, without restriction OR with, weekmonth circle one, and NOTE Rule requires the employer allowing you to move forward further.

Filling out section 2 in Form Twcc 3

3. Completing Fulltime employee who regularly, Seasonal employee who as regular, Parttime Regular Course of Conduct, Minor employee less than years of, Parttime Not Regular Course of, Student employee enrolled in a, Apprentice employee who is, Trainee employee undergoing, SAME OR SIMILAR EMPLOYEE, The wage information on this form, The Injured Employee OR, A Similar Employee NOTE If, If the employee was not employed, NOTE TO INJURED EMPLOYEE If you, and TWCC Rev Page of FP TEXAS is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Form Twcc 3 completion process explained (stage 3)

4. To move ahead, the next section will require typing in several blanks. These include WAGE INFORMATION INSTRUCTIONS, Employee Name Social Security, The employer shall report all, If reporting weekly earnings use, PECUNIARY WAGE INFORMATION, Pecuniary Wages include all wages, TOTALS, PERIOD Week Month or BiWeek, TO DATE, HOURS WORKED, and GROSS WAGES EARNED, which you'll find essential to continuing with this document.

If reporting weekly earnings use, Pecuniary Wages include all wages, and PERIOD Week Month or BiWeek inside Form Twcc 3

It's very easy to make errors when filling out your If reporting weekly earnings use, hence you'll want to reread it prior to deciding to send it in.

5. Lastly, the following last part is precisely what you have to complete before using the PDF. The fields in question are the next: Health Insurance, Laundry Cleaning, Clothing Uniforms, Lodging Housing, Food Meals, Vehicle Fuel, Other, To Injury YES NO, YES, and TWCC Rev Page of FP TEXAS.

The best way to fill in Form Twcc 3 portion 5

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