Request for Additional Wage Information - Form E-30
To obtain from you the information we need to determine the eligibility of one of your employees for temporary disability benefits. (See Form)
We will mail this form to you for completion ONLY IF we need a week-by-week breakdown of wage information to properly determine a claimant’s entitlement for temporary disability benefits.
Use by Employer
This form will identify the claimant by name and Social Security number, will show the mailing date, and will specify the period of time for which wage information is needed. You are required to complete the form and return it within 10 days of the mailing date to the address shown on the form.