OhioBWC - Common - Form:  (C-94-A) - Introduction
Wage Statement (C-94-A)
Introduction
Employers or injured workers should use this form to submit the injured worker's earning information. Employers can complete and submit this form online. Injured workers can complete the form online, however, they must print and submit it via fax or mail, since supporting documentation such as payroll stubs, W-2s or any other proof of earnings must be included. If the injured worker cannot provide supporting documentation, the Affidavit section of the form should be completed and notarized. If the injured worker has worked for multiple employers, this documentation should be attached.
Note: Only enter gross earnings, and make no deductions for Social Security, pensions, unemployment insurance, etc.
Required information
  • If the injured worker requests wage loss compensation, list the dates being requested.
  • If the employee receives meals, lodging, tips, etc. in addition to wages, list these.
  • If the employee receives wages, meals, lodging, health and accident benefits, or any other employee paid benefits during period of disability, list these.
  • The gross earnings for the year immediately prior to injury should be entered where possible.
    Deductions for Social Security, pensions, insurance, unemployment, etc., should not be included. Please submit an entire year's worth of earnings where possible in order for BWC to accurately compute the rate of compensation.
  • If the employee did not work during any period in the year prior to injury, list the reasons below, e.g., layoffs, illness, plant shutdown.
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