I get a lot of questions about the proper time frame to file a wage statement. In that regard, I wanted to provide everyone with the Tennessee Department of Labor’s official position which can be found at http://www.tn.gov/labor-wfd/wcomp/pdf/wc_C41_PolicyChange.pdf
FORM C-41 WAGE STATEMENT
Pursuant to T.C.A. Section 50-6-201 (c ), an insurance carrier, employer or self-insured employer shall file a wage statement on a Form C-41, Wage Statement, a form prescribed by the Tennessee Department of Labor & Workforce Development, Workers’ Compensation Division. The Form C-41 must be properly completed and filed with the Division within thirty (30) calendar days of the notice of the injury if one of the following occur:
- If the injured worker suffers a work-related injury that results in the employee not returning to work within seven (7) days after the accident,
- If the work-related injury results in death, or
- If the work-related injury results in permanent impairment.
However, notice the requirements outlined above are very different from the reporting requirements which are outlined in Rule 0800-2-14-.03 – REPORTING REQUIREMENTS. Rule 0800-2-14-.03 states in pertinent part:
(1) In order to ensure that Workers’ Compensation claims are acted on promptly, employers shall report verbally or in writing all known or reported accidents to their insurer within one working day of knowledge of injury.
(2) Every insurer shall file with the Division a report of accident on Form C-20 (Tennessee Employer’s First Report of Work Injury) pursuant to Rule 0800-2-1-.06. Effective January 1, 1998, Form C-20 shall require the signature of the injured employee. If the injured employee is unable to sign the form or refuses to sign the form, an explanation shall be required.
(3) A wage statement to insure the correct rate of compensation shall be filed with the Division and shall accompany the Form C-22 (Notice of First Payment of Compensation) or Form C-23 (Notice of Denial of Benefits). Filings shall be made pursuant to Rule 0800-2-1-.07.
Authority: TCA §50-6-419 and 50-3-702. Administrative History: Original rule filed on December 15, 1997; effective February 28, 1998.
It goes without saying that the wage statement must detail the injured worker’s wages for the 52 weeks prior to the injury. However, if the employee did not work 52 weeks prior to the injury with the employer, the wage statement must reflect all wages earned and the applicable number of weeks that the employee worked for the employer. In addition, those particular claims require that the specific fields, RATE PER DAY, PER HOUR and AVERAGE PER WEEK be completed accurately.
Effective July 1, 2007, the Workers’ Compensation Division will no longer accept printouts, adding machine tapes or any other attachments to the Form C-41 Wage Statement. It is most important that the Employee’s name, Social Security number, State File number, Insurer Claim number and Date of injury fields be filed out accordingly on each wage statement submitted to the Division. The itemized weekly gross wages should be totaled and the resulting Average per week computed.
Incomplete Form C-41 wage statements will not be accepted by the Division and will be returned to the insurance carrier, employer or self-insured. The latest version of the Form C-41 wage statement is available online at the Workers’ Compensation homepage, at http://www.state.tn.us/labor-wfd/forms/c41.pdf
Upon approval by the Division, the C-41 can be replicated with other software which would allow for the form to be computer generated. It is important that the location/positions of the data fields are not modified or deleted. For approval, send the form to Bonnie.Hudgens@state.tn.us or fax the form to (615) 532-1942.