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The Ohio BWC 1217 form, also known as the C-94A Wage Statement, plays an integral role in ensuring injured workers receive the compensation they deserve following a workplace injury. This document requires careful completion by employers to report an injured worker's gross earnings before deductions such as taxes and insurance, and it includes earnings from paid holidays, vacation, and sick leave. The form not only facilitates the reporting of regular and overtime earnings but also accounts for bonuses, commissions, and other types of payments, specifying the importance of prorating certain earnings. Employers are instructed to report earnings based on when they are earned rather than paid, providing a clear timeframe that aligns with the employer’s pay cycle but excludes wages earned after the injury date. Injured workers are highlighted as responsible for the timely submission of wage statements to avoid delays in compensation and are provided guidance on alternative documentation if employer reports are unavailable. Additionally, this form stresses the honesty and accuracy of the information provided with a stern warning about the consequences of fraud. The Ohio BWC 1217 form underscores the cooperative effort between employers, injured workers, and other employers in accurately documenting earnings to ensure appropriate compensation calculation, thereby reflecting its critical role in the workers' compensation process.
Example - 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 | Description |
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| Form Identification | The form is identified as BWC-1217, originally known as C-94A Wage Statement. |
| Purpose | Its main purpose is to report gross earnings of injured workers for the accurate calculation of compensation benefits. |
| Inclusions | Earnings include all pre-deduction amounts such as taxes and insurance, and may encompass bonuses, allowances, and paid leave among others. |
| Governing Law | This form operates under the guidelines of the Ohio Bureau of Workers' Compensation (BWC) and adheres to the regulations set forth by Ohio state law. |
Detailed Instructions for Using Ohio Bwc 1217
Filling out the Ohio BWC Form 1217, also known as the Wage Statement, is a crucial step in ensuring the correct handling of workers' compensation claims. This document helps in the calculation of compensation rates for employees who have suffered a workplace injury. The accuracy and completeness of this form are vital for a smooth process in determining the benefits entitled to the injured worker. Here are the steps to follow in filling out this form.
- Begin by entering the injured worker's name at the top of the form.
- Fill in the date of the injury, claim number, and both the phone number and cell number of the injured worker.
- Next, provide the employer's name along with their phone number and email address.
- Under the section titled "This form was completed by:", check the appropriate box to indicate if the form is being filled out by the employer, the injured worker, or another employer.
- Enter the injured worker's date of hire.
- For the pay period that ended just before the injury, add the pay period begin date and pay period end date.
- Report earnings from the last seven days of that pay period, including regular earnings, overtime earnings, and the total gross earnings.
- If the worker was employed for less than a full pay period before the injury, include the number of hours they were scheduled to work in the week of the injury and their hourly rate.
- Describe any bonuses, allowances, or other payments received, including the nature and time period over which they were earned.
- In the provided space, add any additional information that may impact the calculation of the worker's Full Weekly Wage (FWW) or Average Weekly Wage (AWW), such as periods of unemployment.
- Check the frequency at which the payment is made (e.g., weekly, every two weeks, twice a month, monthly, or other) and fill out or attach the earnings information for the 52 weeks prior to the injury, starting from the pay period that ended immediately before the date of injury.
- For each reported pay period, list the pay period end date, gross amount earned, any other earnings, and a description of exceptions or adjustments.
- The employer must sign and enter their title at the bottom of the form to certify the information's accuracy.
- If necessary, complete the affidavit portion at the bottom of the form. This includes the State of Ohio county name, the Social Security number of the one swearing the affidavit, and the full earnings from the listed employers. This must be signed in the presence of an official who can attest to the oath taken.
- Lastly, ensure that all provided information is double-checked for accuracy and completeness before submission to avoid any potential delays in the claims process.
After the form is completed and signed, it should be submitted to the appropriate department or official as instructed by the Ohio Bureau of Workers' Compensation (BWC). Timely and accurate completion of this form plays a critical role in facilitating the workers' compensation process, ensuring that injured workers receive the support they need during their recovery period.
What You Should Know About Ohio Bwc 1217
What is the Ohio BWC 1217 form used for?
The Ohio BWC 1217 form, also known as the Wage Statement, is used by employers, injured workers, or other relevant parties to report the gross earnings of an injured worker prior to their injury. This form plays a crucial role in determining the compensation rate for workers' compensation claims by detailing earnings, including regular pay, overtime, bonuses, and other types of payments for the period leading up to the injury.
Who needs to complete the Ohio BWC 1217 form?
This form must be completed by the employer of record when an employee has suffered a work-related injury. However, if the injured party is self-employed, unemployed, or was employed by someone other than the employer of record in the claim during the year prior to the injury, the injured worker themselves may need to complete and sign this form. Additionally, other employers may need to fill out the form if they employed the injured worker during the specified timeframe.
What information is required on the Ohio BWC 1217 form?
The form requires detailed information about the injured worker's earnings, including the dates of the pay periods, gross amounts earned, and a description of any bonuses, allowances, or other types of payments. It also requires personal information about the injured worker, details regarding the employment and injury, and a certification that the information provided is accurate.
How are earnings reported on the Ohio BWC 1217 form?
Earnings should be reported based on the period they were earned, not when they were paid. This includes all gross wages before deductions such as taxes or retirement contributions. Payments for holidays, vacation, personal, or sick leave used (but not unpaid leave) should be included. Bonuses and commissions need to be prorated over the time they were earned.
What happens if the Ohio BWC 1217 form is not filed?
Failure to file the Wage Statement in a timely and accurate manner may delay the processing of workers' compensation claims or adversely affect the determination of compensation rates. For injured workers, it is essential to submit this form along with any required documentation to ensure proper calculation of benefits.
Can I attach additional documentation to the Ohio BWC 1217 form?
Yes, additional documentation such as weekly earnings reports, W-2s, Social Security reports, or 1099 forms can be attached to the form. However, if a 1099 form is submitted, it must be accompanied by information reported to the IRS or a sworn statement regarding expenses related to that income. These documents help in accurately determining earnings and any periods of unemployment.
Is it necessary to complete an affidavit with the Ohio BWC 1217 form?
An affidavit is not required for the employer of record unless they are also the injured worker. Self-employed or unemployed individuals completing the form will need to complete and sign the affidavit section. The affidavit helps to verify the accuracy of the reported earnings and is a crucial part of the form that provides legal attestation to the information provided.
Common mistakes
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Failing to complete and sign the wage statement is a common mistake, leading to delays in processing the compensation claim. Both the employer and, if applicable for self-employed or unemployed individuals, the injured worker must ensure the form is filled out correctly and submitted.
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Not reporting gross earnings accurately is another error. Gross wages should include all earnings before any deductions, such as taxes or insurance, and should cover all types of compensation received, including paid leave and bonuses.
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Some individuals mistakenly report earnings based on when they were paid rather than when earned. It's crucial to report earnings for the pay period they were earned to avoid inaccuracies in wage calculations.
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Affidavit sections are often overlooked by those who are required to complete them, including self-employed or unemployed individuals. Completing the affidavit is vital for these parties to attest to the accuracy of their reported earnings.
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Errors in documenting employment periods with other employers during the year prior to the injury can occur. It's important to obtain and accurately report earnings from all applicable employers, not just the employer of record in the claim.
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Failure to provide salary details as per the specific pay periods can result in incorrect compensation calculations. Information should be precise, reflecting the full pay period that ended prior to the injury, including both start and end dates.
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Incorrectly reporting or entirely omitting bonuses, allowances, or other payments outside of regular earnings can skew the wage statement. All compensation, including bonuses and any allowances, should be properly described and prorated if necessary.
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Not adjusting report periods in alignment with the employer’s pay cycle can lead to confusion and potential errors in the wage calculation. It's essential to align the reporting periods with the actual work and compensation schedule.
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Misunderstanding which types of earnings should be reported can result in incomplete wage statements. For example, reimbursements for expenses like travel are not considered earnings and should not be reported as such.
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Finally, inaccurately recounting periods of unemployment in the space provided on the form can adversely affect the calculation of wages. Full transparency regarding periods of unemployment is necessary for accurate wage determination.
Documents used along the form
When working with the Ohio BWC form 1217, also known as the Wage Statement, several other forms and documents often support or are required along with it for processing workers' compensation claims. These documents contribute to ensuring the injured worker's compensation is calculated accurately and fairly, based on their earnings and situation before the injury.
- First Report of an Injury, Occupational Disease or Death (FROI): This form initiates the workers' compensation claim process by documenting the initial details of the injury or occupational disease.
- Medical Records: Comprehensive medical records support the claim by providing details of the injury, treatment plans, and the projected recovery period.
- Authorization for Release of Medical Information (C-101): This form grants permission to release the injured worker's medical records to the Ohio Bureau of Workers' Compensation for review.
- Medication Request Form: Used by healthcare providers to request approval for prescription medications for the injured worker.
- Physician’s Report of Work Ability (MEDCO-14): This form details the injured worker's ability to return to work, including any restrictions or work modifications needed.
- Wage Verification Form: Used in addition to the Wage Statement for verifying the injured worker’s earnings with their employer(s) to accurately calculate compensation rates.
- Temporary Total Disability Compensation Application: This application is necessary for workers seeking compensation for wages lost due to a temporary inability to work.
- Permanent Partial Disability Award Application: For workers who have sustained a permanent impairment but can still perform some work, this application is used to determine eligibility for compensation.
Each of these documents plays a unique role in the workers' compensation claim process, from initiating the claim, through determining compensation, to addressing ongoing medical needs. It's important for both employers and workers to understand the purpose of these documents to ensure the claims process proceeds smoothly and all parties involved are fairly represented and compensated.
Similar forms
The Ohio BWC 1217 form, also known as a Wage Statement, shares similarities with several other types of legal and financial documents, each designed to capture specific data related to employment and earnings. For example, the form closely resembles the Federal W-2 form, which is used by employers in the United States to report an employee's annual wages and the amount of taxes withheld from their paycheck. Both documents serve to report earnings although the W-2 provides a year-end summary for tax purposes, while the BWC 1217 focuses on earnings at the time of an injury for compensation purposes.
Another similar document is the 1099 form used by the IRS for reporting income other than wages, salaries, and tips. This form applies to independent contractors and freelancers, akin to the BWC 1217's provision for reporting earnings if the injured worker is self-employed. Both require detailed earnings reporting and may necessitate accompanying documentation or affidavits to verify the reported income.
The Unemployment Compensation Quarterly Tax Return is also comparable in its function to the BWC 1217 form. While the tax return is used by employers to report wages paid to employees and calculate unemployment taxes due, the BWC 1217 form collects wage information to assess benefits for an injured worker. Each plays a crucial role in ensuring the accurate calculation of benefits based on recorded earnings.
Workers' compensation insurance forms, in general, share a common goal with the BWC 1217 form. These forms are used to initiate a claim process after an employee has been injured on the job. They require detailed information about the employee, the employer, and the circumstances leading up to the injury, similar to the BWC 1217’s requirement for earnings details pre-injury to evaluate compensation.
The FMLA (Family and Medical Leave Act) Certification forms are another related type of document. While these forms are utilized to certify the need for leave due to medical reasons, they also require detailed employment information, including hours worked and wages earned, which mirrors the type of information gathered by the BWC 1217 form for compensatory reasons.
Payroll reports generated by employers for internal use or by payroll service providers also bear resemblance to the BWC 1217 form. These reports detail an employee’s earnings, deductions, and net pay over a period which is critical for the BWC 1217 form to accurately determine the compensation for an injured worker based on their earnings prior to the injury.
Lastly, disability insurance claim forms, which employees use to request benefits when they are unable to work due to a disability, share similarities with the BWC 1217 form. Both require detailed income information and verification of earnings to process the claim. The purpose of both documents is to ensure that individuals receive compensation aligned with their earnings when they are unable to work.
In summary, the Ohio BWC 1217 form is part of a broader ecosystem of documents designed to capture employment and earnings information for a variety of purposes, from tax reporting to benefit assessments. Its focus on capturing detailed earnings around the time of a workplace injury links it closely with other document reporting requirements across legal and financial spheres.
Dos and Don'ts
When completing the Ohio BWC 1217 form, it's important to follow specific guidelines to ensure the accuracy and completeness of the information provided. Below are the things you should and shouldn't do:
What You Should Do:
- Ensure that all sections of the form are completed, including providing information about the injured worker, the employer, and details regarding wages.
- Report gross earnings accurately, including all forms of compensation received prior to deductions such as taxes, insurance, and retirement contributions.
- Include information on earnings from paid holidays, vacation, personal, or sick leave used during the period in question.
- Prorate earnings that are not regular, such as bonuses and commissions, to accurately represent the injured worker's compensation.
- Attach additional documentation if necessary, especially when detailed earnings records are unavailable, including W-2s, Social Security reports, or 1099 forms accompanied by relevant expense statements.
- Ensure that the form is signed by the required parties, verifying that the information provided is correct and truthful.
- Include any periods of unemployment or other relevant information that may affect the calculation of Full Weekly Wage (FWW) and/or Average Weekly Wage (AWW).
What You Shouldn't Do:
- Do not omit any earnings, including bonuses, allowances, or other payments received by the injured worker.
- Avoid reporting earnings after the date of injury; only report earnings up to the day before the injury occurred.
- Do not report reimbursable expenses as earnings, such as travel or uniform costs, as these are not considered earnings for wage calculations.
- Avoid submitting the form without ensuring it is fully and accurately completed to prevent delays in processing.
- Do not forget to prorate irregular earnings over the period they were earned to provide a fair representation of the injured worker's wages.
- Avoid submitting the form without the necessary attachments if additional documentation is required.
- Do not hesitate to provide detailed explanations for any earnings anomalies or periods of unemployment to ensure clarity.
Misconceptions
When it comes to navigating the complexities of workers' compensation forms in Ohio, specifically the BWC-1217 form or Wage Statement, there are several common misconceptions that can lead to confusion for both injured workers and employers. By clarifying these misunderstandings, both parties can more successfully manage the compensation process.
Misconception 1: The affidavit section must be completed by all employers. In reality, only the injured worker or an alternate employer, not the employer of record, needs to complete the affidavit if they are reporting wages.
Misconception 2: Gross earnings do not include paid leave. Contrary to what some might think, gross wages should include all earnings before deductions, including paid holidays, vacation, personal, or sick leave, as long as the leave was utilized.
Misconception 3: Payments are reported based on when they are made. This is incorrect. Earnings should be reported for the periods they are earned, not when they are paid out, aligningham with the actual earnings period, not the payment date.
Misconception 4: It's unnecessary to report periods of unemployment or payments made during those periods. The form actually requests that you report any periods the injured worker did not work, including descriptions and amounts if payments were made during those times.
Misconception 5: All earnings, including reimbursements, must be reported. It is essential to differentiate that reimbursements for expenses such as travel or uniforms are not considered earnings and should not be reported as such on the form.
Misconception 6: Filing wage statements is optional and has no immediate effects. This statement is misleading. Failure to file wage statements promptly may delay or adversely affect the rates of compensation for injured workers, making timely submission crucial.
Misconception 7: Information provided on a 1099 form is considered as earned evenly throughout the year. While this may be the default assumption, the BWC will consider the timeframe specified unless earnings reported on a W-2, Social Security report, or 1099 form are noted otherwise.
Misconception 8: Bonuses and allowances are reported under regular earnings. In fact, bonuses, allowances, and other payments should be described separately as other earnings, with a clear description of the nature and the period over which they were earned.
Understanding these points helps clear up confusion and ensures that both the injured worker and the employer can fulfill their responsibilities regarding the BWC-1217 form more accurately and efficiently.
Key takeaways
Filling out the Ohio BWC 1217 form, also known as the Wage Statement, is a critical step for both employers and injured workers in the workers' compensation claim process. To ensure accuracy and compliance, here are six key takeaways about completing and using this form effectively:
- Reporting gross earnings accurately is essential. This includes all forms of earnings such as salaries, wages, paid holidays, personal or sick leave used, and even bonuses and commissions, which should be prorated based on the time they were earned, not necessarily when they were paid.
- Both the employer and the injured worker have important roles in the process. Employers are required to complete and sign the wage statement, ensuring it reports the injured worker's gross earnings before any deductions. Meanwhile, injured workers must file wage statements to avoid delays or negative impacts on their compensation rates.
- Self-employed or unemployed injured workers should not overlook their responsibility to complete the form. Including an affidavit is necessary for these individuals, which can be sworn to without cost at a BWC local customer service office.
- For workers employed by multiple employers over the year preceding their injury, it's crucial to obtain wage information from all relevant employers. The form doesn't require the affidavit section to be completed by these additional employers, simplifying the process.
- Alternative documentation like W-2s, Social Security reports, or 1099s can be used when detailed earnings from an employer are unavailable. However, it should be noted that additional information might be required to accompany a 1099 form, including a sworn statement about related expenses or IRS reported information.
- The BWC uses the information provided on the BWC 1217 form to calculate the injured worker's Full Weekly Wage (FWW) and Average Weekly Wage (AWW). These calculations are crucial for determining the compensation rates. Both employers and workers should ensure the data related to gross earnings, payment periods, and any other earnings are reported accurately.
Lastly, both parties should be aware that providing false information on this form can lead to severe legal consequences, including felony charges. Accuracy and honesty in completing the Ohio BWC 1217 form are paramount for a smooth workers' compensation claim procedure.
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