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Employer's Statement Of Wage Earnings (Preceding the Date of Injury/Illness)
EC-240

State of New York - Workers' Compensation Board

THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.

If you have used the previous version of this form, please be aware that some functions such as Adding Attachments have changed. Please read Form Instructions for additional information.

Required items are indicated by an *.

Claim Information - ALL COMMUNICATION SHOULD INCLUDE THESE NUMBERS
Injured Worker Information
Insurer Information
Employer Information
The Tax ID # is the (select one):
Wage Information
To determine Average Weekly Wage, the Board needs the gross weekly earnings for the 52 weekly periods immediately preceding the date of the injury/ illness. This information can be provided by 1) attaching detailed payroll information that indicates days paid and gross weekly earnings; 2) if injured worker is paid by salary and his or her weekly pay does not change from week-to-week, attach document(s) providing their salary information for the previous 52 weeks; or 3) by completing the Injured Worker Payroll section below.

If the injured worker has not worked at the same employment for one year or a substantial part of the year, also attach detailed payroll information for an employee of the same class, or complete the Employee of the Same Class Payroll section of this form. 'Substantial part of the year' does not require any particular number of days worked but as a guideline 234 days at 5 days per week and 270 days at 6 days per week.


* Payroll information is:
INJURED WORKER PAYROLL:
Enter the injured worker's gross weekly earnings for the 52 weekly periods immediately preceding the date of injury/illness. In the "Days Paid" column enter the number of days compensated, including paid time off.
Injured Worker's schedule of gross wage earnings for the 52 weeks immediately preceding the date of accident:
No. Week Ending
Date		 Days
Worked		 Gross amount
paid including
overtime
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
No. Week Ending
Date		 Days
Worked		 Gross amount
paid including
overtime
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
No. Week Ending
Date		 Days
Worked		 Gross amount
paid including
overtime
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
* Did this employee's compensation include board, rent, housing, tips and/or gratuities in addition to the above earnings?

  day week.

* Was there any wage adjustment made that affected the 52-week period? (If injured worker was in military service, please indicate and provide date of discharge.)
* Was the injured worker laid off during the preceding 52 weeks?
Employee of the Same Class Information
EMPLOYEE OF THE SAME CLASS PAYROLL:
If the injured worker has not worked at the same employment for one year or a substantial part of the year, enter the gross weekly earnings for an employee of the same class. "Substantial part of the year" does not require any particular number of days worked, but as a guideline 234 days at 5 days per week and 270 days at 6 days per week.


Same Class Employee Payroll information is:

Employee of the Same Class:


Week
No. 		Week Ending
Date		 Days
Paid		 Gross Amount
Paid including
Overtime
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Week
No. 		Week Ending
Date		 Days
Paid		 Gross Amount
Paid including
Overtime
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
Week
No. 		Week Ending
Date		 Days
Paid		 Gross Amount
Paid including
Overtime
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
An employer or insurer, or any employee, agent, or person acting on behalf of an employer or insurer, who KNOWINGLY MAKES A FALSE STATEMENT OR REPRESENTATION as to a material fact in the course of reporting, investigation of, or adjusting a claim for any benefit or payment under this chapter for the purpose of avoiding provision of such payment or benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISIONMENT.

Prepared By - The information is true and to the best of my knowledge and belief.

If you have used the previous version of this form, please be aware that some functions such as Adding Attachments have changed. Please read Form Instructions for additional information.

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