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Preview - Ohio Bwc 1217 Form
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Wage Statement |
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Injured worker name |
Date of injury |
Claim number |
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Phone number |
Cell number |
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Employer name |
Phone number |
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Email address |
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Instructions for the employer
Complete and sign this wage statement. It is not necessary for you to complete the affidavit, unless you are also the injured worker.
Report gross earnings. Gross wages include all earnings for the injured worker prior to any deductions such as for taxes, insurance or employee contributions to retirement programs. Include earnings amounts from paid holidays, vacation, personal or sick leave used (but not leave time paid but not used). Earnings are reported in the periods they are earned, not when they are paid. Some earnings such as bonuses and commissions need to be prorated.
Instructions for the injured worker
Failure to file wage statements may delay or adversely affect rates of compensation.
If you are
If anyone other than the employer of record in this claim employed you during the year prior to the date of injury, you must obtain this information from those employers. If your other employer completes this form, it is not necessary for that employer to complete the affidavit.
If detailed earnings from your employer(s) are not available, you can provide other documentation such as
This form was completed by:
Employer of record
Injured worker
Other employer
You must provide this information, even if you are providing weekly earnings on an attached report.
Date of hire
Provide information based on pay period begin and end dates, not payment dates.
For the full pay period that ended prior to the date of injury:
Pay period begin date
Pay period end date
During the last seven days of that pay period:
Regular earnings
Overtime earnings
Total gross earnings
If employed less than one full pay period prior to the date of injury, provide the following information:
Number of hours scheduled the week of the injury
Hourly rate
If the injured worker received any bonuses, allowances or other payment, please describe the nature of the payment and time period over which it was earned below. You may also provide other information for us to consider in the calculation of FWW and/or AWW such as periods of unemployment in the space below.
Injured worker name
Claim number
Wage Statement
You may submit earnings by providing a report that includes the required information as described below or by completing this worksheet.
Report the pay period dates, not the date payment was made.
Report any periods the injured worker did not work. If payment was made during those periods, report the amount and description of payment the injured worker received.
If the employee received an allowance for meals, lodging, tips, etc in addition to wages, report as other earnings with a description of the earnings. It is not necessary to report reimbursements made to the injured for travel, uniforms, etc. BWC does not consider reimbursements earnings for calculations of wages.
If the injured worker received a bonus during the reporting period, report as other earnings with a description of the earnings which includes the period of time over which it was earned.
Report earnings beginning with the full pay period that ended prior to the date of injury. When setting the
periods to report, you may adjust the reporting periods backward to line up the reporting time frames with the employer’s pay cycle. Do not report wages earned on or after the date of injury.
Payment is made (check one)
Weekly |
Every two weeks |
Twice a month |
Monthly |
Other |
Use the worksheet below, or attach other documentation to provide earnings information for the 52 weeks prior to the date of injury, beginning with the full pay period prior to the date of injury.
Pay period end date |
Gross amount earned |
Other earnings |
Description of exceptions |
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WAGES formerly known as
Wage Statement
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I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain payment as provided by the BWC or who knowingly accepts payment to which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both.
Signature
Date
Employer name and title
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Employer signature and title
Affidavit
State of Ohio, County of __________________________________ Social Security number: __________________________________
being first duly sworn, says that the entire earnings from ___________________ to ___________________ ; as listed above is correct.
If unable to write, mark must be witnessed by two persons.
Sworn to before me, and subscribed in my presence
Signature of applicant
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Official title
WAGES formerly known as
Document Properties
| Fact Name | Details |
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| Purpose | The Ohio BWC 1217 form is a Wage Statement used to report an injured worker's gross earnings. |
| Governing Law | This form is governed by the Ohio Revised Code, specifically sections related to workers' compensation. |
| Completion Requirements | Employers must complete and sign the form. Injured workers must provide accurate wage information. |
| Reporting Earnings | Gross earnings must be reported before any deductions, including bonuses and commissions, which may need to be prorated. |
| Consequences of Non-Compliance | Failure to file this form may delay compensation rates for the injured worker. |
| Affidavit Requirement | If self-employed or unemployed, the injured worker must complete and sign an affidavit included with the form. |
Documents used along the form
The Ohio Bureau of Workers' Compensation (BWC) Form 1217, commonly known as the Wage Statement, is a critical document used in the context of workers' compensation claims. It provides essential information regarding an injured worker's earnings, which is necessary for determining compensation rates. Alongside this form, several other documents are frequently utilized to support the claims process. Below is a list of these documents, each accompanied by a brief description.
- Form C-84: This form is used by injured workers to request temporary total compensation benefits. It details the worker's inability to work due to injury and provides information about medical treatment and recovery status.
- Form C-92: This document is a request for a change in the payment of compensation. It is often submitted when there is a change in the worker's earnings or employment status, affecting their compensation.
- Form C-230: The C-230 form is used to report the death of a worker. It serves as a notification for the BWC to initiate the process for survivor benefits for eligible dependents.
- Form C-150: This form is utilized for reporting an employee's injury or illness. It includes information about the incident, the nature of the injury, and the circumstances surrounding it.
- Form C-3: This is the initial claim form filed by the injured worker to report their injury to the BWC. It outlines the details of the injury and the circumstances under which it occurred.
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- Form C-86: This form is a request for a hearing regarding a disputed claim or compensation issue. It allows workers to appeal decisions made by the BWC concerning their benefits.
- Form C-175: The C-175 is used to report any changes in the worker's medical condition. It is crucial for ongoing claims, as it updates the BWC on the worker's recovery progress.
- Form W-2: This document is provided by employers to report an employee's annual wages and taxes withheld. It is often used to verify earnings when completing the Wage Statement.
- Form 1099: This form reports income received by independent contractors or self-employed individuals. It is relevant for injured workers who may not have traditional employment arrangements.
- Social Security Administration Reports: These reports detail earnings and benefits related to Social Security. They can serve as supplementary documentation for the BWC when assessing a worker's income.
Each of these documents plays a vital role in the workers' compensation claims process in Ohio. Properly completing and submitting them can significantly influence the outcome of a claim, ensuring that injured workers receive the benefits to which they are entitled.
Guidelines on Filling in Ohio Bwc 1217
Completing the Ohio BWC 1217 form is essential for accurately reporting wage information related to an injured worker's claim. This process ensures that all necessary details are captured, which can affect compensation rates. Follow these steps to fill out the form correctly.
- Begin by entering the injured worker's name at the top of the form.
- Fill in the date of injury and the claim number.
- Provide the phone number and cell number for the injured worker.
- Enter the employer's name, along with their phone number and email address.
- Employers should complete and sign the wage statement. If the employer is also the injured worker, the affidavit must be completed as well.
- Report gross earnings, which include all earnings before any deductions. Include amounts from paid holidays, vacation, personal, or sick leave used.
- For the full pay period that ended before the date of injury, enter the pay period begin date and pay period end date.
- During the last seven days of that pay period, provide the regular earnings, overtime earnings, and total gross earnings.
- If employed for less than a full pay period prior to the injury, report the number of hours scheduled that week and the hourly rate.
- Describe any bonuses or allowances received, including the time period over which they were earned.
- Check the appropriate box for how payment is made: Weekly, Every two weeks, Twice a month, Monthly, or Other.
- Use the worksheet to provide earnings information for the 52 weeks prior to the injury date, starting with the full pay period before the injury.
- Certify that the information provided is correct by signing and dating the form.
- If applicable, complete the affidavit section, including the Social Security number and dates of earnings.
After completing the form, it is crucial to submit it promptly to avoid delays in compensation. Ensure that all information is accurate and that signatures are provided where necessary. If any additional documentation is needed, gather it to support the information reported on the form.
Common mistakes
Filling out the Ohio BWC 1217 form can be a straightforward process, but there are common mistakes that individuals often make. Understanding these pitfalls can help ensure that the form is completed accurately and efficiently.
One frequent error is failing to report gross earnings accurately. Gross wages should include all earnings before any deductions, such as taxes or retirement contributions. If someone only reports net pay, it can lead to complications in calculating compensation. It’s essential to include all earnings, including those from paid holidays and leave, to provide a complete picture of the worker's income.
Another mistake involves not adhering to the correct reporting periods. Individuals sometimes report earnings based on when they were paid instead of when they were earned. This can confuse the calculation of average weekly wages and may lead to delays in processing the claim. Always ensure that the pay period dates align with the periods for which earnings were actually accrued.
People also often neglect to provide complete information about their employment history. If the injured worker had other employers in the year leading up to the injury, it’s crucial to include that information. Missing this data can result in incomplete earnings calculations, which may affect the compensation received. If another employer completes the form, the affidavit does not need to be filled out by them, but this detail is sometimes overlooked.
Some individuals mistakenly think that they do not need to submit additional documentation if detailed earnings are unavailable. If earnings from the employer are not accessible, it’s important to provide alternative documentation, such as W-2s or Social Security reports. Failing to include this can lead to assumptions about earnings that may not reflect reality.
Additionally, individuals may forget to include allowances or bonuses as part of their earnings. These should be reported separately with clear descriptions. If bonuses are received, it’s essential to note the time period over which they were earned. This oversight can lead to an inaccurate representation of total earnings.
Another common mistake is not completing the affidavit section if the injured worker is self-employed or unemployed. This section is crucial for validating the information provided. If it is overlooked, it could result in delays or complications in processing the claim.
Moreover, people sometimes fail to report periods of unemployment or other exceptions in their earnings. These details are important for the calculation of average weekly wages. Not mentioning these periods can lead to inaccuracies in the final calculations and affect the compensation amount.
Lastly, individuals may not fully understand the importance of signing and dating the form. A missing signature or date can delay processing and lead to further complications. Ensuring that all required fields are filled out completely and correctly is vital for a smooth claims process.
FAQ
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What is the Ohio BWC 1217 form?
The Ohio BWC 1217 form, also known as the Wage Statement, is a document used to report an injured worker's earnings. It is crucial for determining compensation rates after a workplace injury. The form collects information about the injured worker's gross earnings, including wages, bonuses, and other payments, prior to any deductions.
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Who is responsible for completing the BWC 1217 form?
The employer of record is primarily responsible for completing and signing the BWC 1217 form. However, if the injured worker is self-employed or unemployed, they must also complete and sign the form, including the affidavit. If another employer employed the worker within the year prior to the injury, that employer must provide the necessary information as well.
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What information must be reported on the form?
The form requires various details, including the injured worker's name, date of injury, claim number, and contact information. Employers must report gross earnings, which include all forms of compensation before any deductions. This encompasses regular wages, overtime, bonuses, and any allowances. It is essential to report earnings based on the pay period in which they were earned, not when they were paid.
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What happens if the wage statement is not filed?
Failure to file the wage statement can lead to delays or negative impacts on the injured worker's compensation rates. It is vital to ensure that the form is submitted accurately and on time to avoid any disruptions in benefits.
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Can I provide alternative documentation instead of the BWC 1217 form?
Yes, if detailed earnings from the employer are unavailable, the injured worker can submit alternative documentation, such as W-2 forms or Social Security reports. If using a 1099 form, it must be accompanied by a sworn statement regarding any related expenses. The Bureau of Workers' Compensation (BWC) will assume that earnings reported were earned over the entire year unless specified otherwise.
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How should bonuses and commissions be reported?
Bonuses and commissions must be reported as "other earnings" on the form. It is important to describe the nature of these payments and indicate the time period over which they were earned. This ensures that the BWC has a complete understanding of the worker's compensation history.
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What if the injured worker was employed for less than a full pay period before the injury?
If the injured worker was employed for less than a full pay period prior to the injury, the employer must provide the number of hours scheduled for the week of the injury and the hourly rate. This information helps the BWC calculate the appropriate compensation based on available earnings.
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What is the significance of the affidavit section of the form?
The affidavit section is a sworn statement affirming the accuracy of the reported earnings. It is particularly important if the injured worker is self-employed or if another employer is providing earnings information. This section serves as a legal commitment to the truthfulness of the information provided and can have serious consequences if false statements are made.
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What are the potential consequences for providing false information?
Providing false information on the BWC 1217 form can lead to severe legal repercussions. Individuals who knowingly misrepresent facts may face felony criminal prosecution, which can result in fines, imprisonment, or both. Therefore, it is essential to ensure that all information submitted is accurate and truthful.