Ga Form Wc 6 PDF Details

The Ga WC 6 form serves a critical role within the Georgia State Board of Workers' Compensation framework, providing a structured means for calculating an injured employee's average weekly wage. This document facilitates a fair assessment of benefits by requiring detailed wage information from both the employer and a comparable role within the same employment, should the employee not have a sufficient employment history. Key sections include identifying information for the employee, employer, and insurer or self-insurer, in addition to a comprehensive schedule for recording thirteen weeks of gross earnings leading up to the incident. This form not only assists in determining the financial compensation due to the employee but also underscores the state's commitment to protecting workers' rights through meticulous record-keeping and transparency. Instructions for completion are straightforward, with emphasis on the accuracy and honesty of the information provided, underlining the serious legal implications of falsifying documents. This wage statement is an invaluable tool, ensuring that workers are compensated in alignment with their earnings, thereby providing a semblance of security during their recovery period.

QuestionAnswer
Form NameGa Form Wc 6
Form Length1 pages
Fillable?Yes
Fillable fields186
Avg. time to fill out37 min 27 sec
Other namesgeorgia wage statement, wage state statement online, wc6, ga form wc

Form Preview Example

WC-6 WAGE STATEMENT

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

WAGE STATEMENT

Board Claim No.

Employee Last Name

Employee First Name

M.I.

SSN or Board Tracking #

Date of Injury

A. IDENTIFYING INFORMATION

 

 

County of Injury

 

 

Address

 

 

EMPLOYEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

Address

 

 

EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

INSURER/

 

Name

 

 

 

SBWC ID# (five digit number)

 

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

Claims Office Address

 

 

 

 

CLAIMS OFFICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

Insurer/Self-Insurer File #

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

B. COMPUTATION OF AVERAGE WEEKLY WAGE

If the weekly benefit is less than the maximum, complete the schedule below for thirteen (13) weeks immediately preceding the accident. If the employee has not been in your employ for the thirteen (13) weeks, complete this schedule showing gross weekly earnings of a similar employee in the same employment.

13 Weeks of Employee’s Wages

13 Weeks of a Similar Employee’s

Full time weekly wage of injured employees

Wages

 

 

Wage at date of injury per week:

SCHEDULE OF WEEKLY EARNINGS

 

From

To

No. of

Gross

 

Value of Additional Compensation

 

 

 

Amount Paid

 

 

 

 

 

Total

Week

Date

Date

Days

Including

 

 

 

 

 

 

 

 

 

 

Earnings

 

MM/DD/YYYY

MM/DD/YYYY

Worked

Overtime or

Meals

Lodging

Rent

Tips

Other

 

 

 

 

 

 

Extra Work

 

 

 

 

 

 

1

2

3

4

5

6

7

8

9

10

11

12

13

Total

Average Weekly Earnings

C.

REMARKS:

REQUIRED TO COMPLETE:

OFF

Mon

Tue

Wed

Thur

DAYS

Fri

Sat

Sun

 

 

 

Type or Print Name

E-mail Address

Signature

Date

 

 

Phone Number

IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov

WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19).

WC-6

REVISION . 07/2011

6

WAGE STATEMENT

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Step 2: You are now free to edit wage statement ga. You possess many options thanks to our multifunctional toolbar - you'll be able to add, eliminate, or alter the information, highlight its selected parts, as well as undertake other sorts of commands.

The next areas are within the PDF template you will be filling in.

portion of gaps in wc 6 compensation

The application will require you to submit the Full, Time, Weekly, Wage, of, Injured, Employee SCHEDULE, OF, WEEKLY, EARNINGS Gross, Amount, Paid Including, Overtime, or, Extra, Work Week, From, Date MM, DD, YYYY To, Date MM, DD, YYYY No, of, Days, Worked Total, Average, Weekly, Earnings Value, of, Additional, Compensation Meals, and Lodging area.

Completing wc 6 compensation step 2

Note the main information in Sun, No, Off, Days C, SCHEDULED, DAYS, OFF REMARKS, Type, or, Print, Name, Email, Address D, REMARKS Signature, Date, Phone, Number REVISION, and WAGE, STATEMENT part.

stage 3 to completing wc 6 compensation

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