INSTRUCTIONS FOR COMPLETING
THE
TWCC-3

The TWCC-3, Employer's Wage Statement is used to report an injured employee's wages when the employee has lost time from work due to the injury.

PAGE 1

Check the appropriate block at the top of the form to indicate if this is the initial wage statement or an amended statement.

Blocks 1-6 - Self explanatory.

Block 7 - Leave blank

Block 8 - Self explanatory

Block 9 - Check the appropriate block and if returned to work, indicate the date returned.  Also check if the employee returned to full duty and pay ot reduced.

Block 10 - Check all the blocks that apply to the injured employee's status.

Page 2

Complete the information at the top for the employee's name, Social Security number and date of injury.

Check if the information to follow is for the injured employee or for a similar employee.  Use the information for a similar employee if the injured employee has not worked enough to hade information for a full 13 week period PRIOR to the injury.

Blocks 11a-c - Wage information - Use the instructions to the left of the block on the form.  When completing this information DO NOT use the day of the injury for information or any days after the injury.  Place the from and to dates (include weekends), the number of hours of work for which the employee was paid and the gross pay.  If the employee is paid only once a month use the instructions to the left of the block at the bottom to compute the information. Be sure to complete information for all 13 weeks.

Page 3

Complete the information at the top for the employee's name, Social Security number and date of injury.

Blocks 12 a-d - Complete the information about any benefits provided by the employer.  If there is none, check no in the blocks of 12a.  If yes check the blocks and insert the appropriate value.  Also check if the employer continues to provide these benefits.  When the employee is off from work but is using sick leave and/or regular leave, this information is still required. If you need assistance with this section, for COALS/TAES employees, contact Patsy Shoppe at 979-845-4775.  For TCE, contact Donna Cooper at 979-845-7991.

Page 4

Print the name and title of the person completing the form, then sign and date the form. THIS CANNOT BE THE INJURED EMPLOYEE!