Employer’s Wage Statement (DWC-3)

Online entry of the DWC-3 is available through SORM’s secure portal, RMIS.

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.

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.

Indicate the employment status prior to the work injury. Check all boxes that apply.

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.

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

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.

The Employer’s Wage Statement (DWC-3) form must be signed and dated by the person completing the form.

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.

Agency Violations

DWC-3, Employers Wage Statement Texas Labor Code ?408.063 and DWC Rule 128.2An employer shall file a signed wage statement with the carrier and the employee within 30 days of the date benefits begin to accrue and with the commission within 7 days of receiving a request from the commission.An employer that fails to file a complete wage statement as required by this rule without good cause may be assessed an administrative penalty, not to exceed $500 unless it is part of a pattern of practice which is subject to a penalty not to exceed $10,000.