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Online entry of the DWC-3 is mandatory
Required:
Immediately after receiving notice of an injury, the agency should complete
the employee's wage statement. This information is needed when the employee
experiences one (1) or more full days of lost time or as requested by
SORM.
If a fringe benefit is identified as being continued, and the employer
later suspends that benefit, the employer must file an amended DWC-3
form with SORM within three (3) calendar days of reporting the date of
suspension.
Filing Deadline:
The form must be received by SORM not later than the 5th calendar day
after the first full day of lost time.
Completed by:
The claims coordinator or agency representative.
Instructions for the DWC-3:
Please follow these steps when completing the Employer's Wage Statement
(DWC-3) form.
First, indicate whether the DWC-3 is being submitted for the first time
or if it is an amendment to a previously submitted DWC-3 by placing an
"X" in either the "Initial" box or the "Amended" box.
STEP ONE: EMPLOYER AND EMPLOYEE INFORMATION
Boxes are self-explanatory. Please complete all boxes.
Indicate the employee's
status according to the guidelines included on the form.
Sign and date this
form.
STEP TWO: EMPLOYMENT
STATUS AT TIME OF INJURY
Indicate the employment status prior to the work injury. Check all boxes
that apply.
STEP THREE: SAME
OR SIMILAR EMPLOYEE
If the employee was not employed by the agency for 13 continuous weeks
before the date of injury, the claims coordinator shall base the injured
employee's wages on an employee performing similar services. If using
a similar employee, put a check in the appropriate box.
STEP FOUR: PRECUNIARY WAGE INFORMATION
Provide all wage information for each week in the 13 weeks immediately
preceding the date of injury. Do not include the date of injury or any
days after the date of injury. Earnings to be included under "Gross Weekly
Pay" are: Benefit Replacement Pay, Longevity Pay, Hazard Pay, Sick or
Annual Paid, and Shift Differential Pay. Do not include any fringe benefits
in these calculations. Follow the instructions included on the DWC-3
for boxes 11a, 11b, and 11c.
Employees hired by the State of Texas on or before August 31, 1995, may
be eligible for Benefit Replacement Pay (BRP), beginning with wages paid
on January 1, 1996. The 74th Legislature eliminated the provision for
the State to pay a portion of the employees' share of Federal Insurance
Contribution Act (FICA) taxes, commonly referred to as state-paid social
security. The BRP is intended to compensate employees for the loss of
the state-paid share. New employees hired on September 1, 1995, or later,
are not eligible for the BRP.
The formula for calculating Gross Weekly Pay is:
Monthly Gross Wages ÷ 4.34821 = Gross Weekly Pay
Examples for Wage Information:
The following are examples of how to complete precuniary wage information.
The sample form illustrates these boxes.
Employee John Doe was injured on 8/12/96 after falling off
a warehouse ladder. John had a Monthly Gross Wage of $1,300. John was
a full-time state employee and worked Monday through Friday. To calculate
his wages, take the following steps:
First and second rows: Fill in the dates for all 13 weeks prior to the
date of injury, starting with the date before the injury occurred.
Third row: Fill in the number of hours paid for all 13 weeks prior to
the date of injury, starting with the date before the injury occurred.
Fourth row: Calculate the Gross Weekly Pay by dividing the Monthly Gross
Wages by 4.34821.
$1,300 ÷ 4.34821 = $298.97
Employees' wages will sometimes change at the end of a month, midway through
a work week. In this example, John received a $100 / month raise beginning
August 1, 1996, which fell on a Thursday. This is Week 2 on the sample form.
Take the following steps to calculate Gross Weekly Pay when two different
Monthly Gross Wages combine during one work week:
- Calculate the Daily Wage of the worker for both monthly salaries.
To do this, first calculate the Gross Weekly Pay for both Monthly Gross
Wages as usual.
Previous Monthly Gross Wage ÷ 4.34821 = Previous Gross Weekly Pay
John's Previous Gross Weekly Pay: $1,300 ÷ 4.34821 = $298.97
New Monthly Gross Wage ÷ 4.34821 = New Gross Weekly Pay
John's New Gross Weekly Pay: $1,400 ÷ 4.34821 = $321.97
- Divide the Gross Weekly Pay of each salary by the number of days worked
each work week to obtain the Daily Wage.
Previous Gross Weekly Pay ÷ 5 days worked = Previous Daily Wage
John's Previous Daily Wage: $298.97 ÷ 5 = $59.79
New Gross Weekly Pay ÷ 5 days worked = New Daily Wage
John's New Daily Wage: $321.97 ÷ 5 = $64.39
- Add the number of days worked under the Previous Daily Wage to the
number of days worked under the New Daily Wage and the total will be
the Gross Weekly Pay for that week.
John worked Monday - Wednesday, July 29, 30, and 31: 3 days
John worked Thursday - Friday, August 1 and 2: 2 days
Previous Daily Wages + New Daily Wages = Gross Weekly Pay
($59.79 x 3 days) + ($64.39 x 2 days) = Gross Weekly Pay
$179.37 + $128.78 = $308.15
John's Gross Weekly Pay is $308.15 for Week 2, July 29 - August 4, 1996.
Use John's new Monthly Gross Wage of $1,400 to calculate the Gross Weekly
Pay for Week 1, August 5 - 11, 1996.
$1,400 ÷ 4.34821 = $321.97
STEP FIVE: NONPECUNIARY WAGE INFORMATION
Do not include fringe benefits in pecuniary wage calculations section. Also,
always use the injured employee's fringe benefits, even if the wages are
based on those of a similar employee.
If the injured employee is entitled to any of the fringe benefits listed,
the claims coordinator should check "YES" in the appropriate box.
Boxes 1-13: State the value or dollar amount of the benefit(s) paid each
week prior to the injury. When provided with a monthly amount of benefits
paid, divide the monthly amount by 4.34821 for the weekly fringe benefit.
Please give the amount of the state contribution for health insurance, not
the total charge for health insurance. Do not include employee contributions.
Please note that the state contribution for health insurance can be affected
by the Family Medical Leave Act. Check with your human resources office
if in doubt of any benefits.
Indicate whether the employer will continue to provide the fringe benefit(s).
Indicate the date the fringe benefit(s) were or will be suspended.
*** If a fringe benefit is identified as being continued, and the employer
later suspends that benefit, the employer must file an amended DWC-3 form
with SORM within three (3) calendar days of reporting the date of suspension.
Example for Nonpecuniary Wage Information
John Doe received a state contribution of $176.93 a month for health insurance.
To convert this figure to a weekly amount, use the following formula:
Monthly Fringe Benefit Amount ÷ 4.34821 = Weekly Fringe Benefit Amount
$176.93 ÷ 4.34821 = $40.69 / week
Write the figure "$40.69" for all 13 weeks in Box 12b beside the Health
Insurance box.
In situations where a Monthly Fringe Benefit Amount changes at the end of
a month, midway through a work week, please follow the same steps as illustrated
for changing wages at the end of the month.
IMPORTANT
The Employer's Wage Statement (DWC-3) form must be signed and dated by
the person completing the form.
Distribution:
Fax a copy or mail the original to:
State Office of Risk Management
Mail a copy to the claimant.
Retain a copy for your file.
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