Mdwcc Form C 2 – Fill Out and Use This PDF

WORKERS' COMPENSATION COMMISSION

Statement of Wage Information

The information below is provided pursuant to COMAR 14.09.01.07 and LE, §9-602(a)(2), Annotated Code of Maryland.

This form should be submitted before the consideration date or to provide updated wage information. When a claim has already been filed, a copy of this form shall be sent to the Workers' Compensation Commission and the claimant or his/her attorney.

Injured Employee Name:	Date:
Social Security Number:	WCC Claim Number:

*Was this employee provided free rent, lodging, board, tips or other allowances in addition to the above earnings? If “yes”, the weekly or bi-weekly value must be included in the "Other Allowances" Column.

When the employee is paid weekly, complete each row for the most recent 14 weeks where wages were paid. If paid alternate weeks please enter in the clear, even-numbered rows. If paid on any other schedule, please use the worksheet on page 2 to calculate the average weekly

wage. If less than 14 weeks were worked by the employee, use the worksheet on page 2.

	Week #		Week Ending	Days Worked		Gross Wages			Other Allowances*				Total
			(MM/DD/YYYY)			including overtime							Amount Paid
	1
2
	3
4
	5
6
	7
8
	9
10
	11
12
	13
14
	TOTALS
					divided by number weeks					= Average Weekly
	TOTAL				worked (where wages are		14
										Wage
					paid/indicated)

CERTIFICATION OF SERVICE -

I hereby certify that on the above date, a copy of this Statement of Wage form was mailed to the Workers' Compensation Commission and the claimant or his/her attorney.

SUBMITTED BY:

Name

Signature

Company

Title

Street

City

State

ZIP Code

Telephone

Email

10 East Baltimore Street Baltimore, Maryland 21202-1641

410-864-5100฀

Email: info@wcc.state.md.us

Web: http://www.wcc.state.md.us฀

MDWCC Form C-2 (05/2014)

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WORKERS' COMPENSATION COMMISSION

Statement of Wage Information

CALCULATION OF AVERAGE WEEKLY WAGE WHEN CLAIMANT

IS PAID OTHER THAN WEEKLY OR BI-WEEKLY (Monthly, Semi-Monthly or other,฀attach฀details)

A.

Inclusive dates used in wage statement

to

B.Number of days used in calculation (Minimum 98 days to capture 14 weeks)

C.Gross wages

(including overtime, free rent, lodging, board, tips & other allowances)

D.Daily Rate (C ÷ B)

E.Average Weekly Wage (D x 7)

Average Weekly Wage (E) =

(Please enter this amount on page 1 as Average Weekly Wage)

10 East Baltimore Street Baltimore, Maryland 21202-1641

410-864-5100฀ Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us฀

MDWCC Form C-2 (05/2014)

Page 2 of 2