4-5 Use current home phone and address. 9 Job title as shown on personnel records. 12 Marital status must show single, married, divorced, or widowed, as the case may be. A divorced or widowed person should not be shown as single. Be sure wages are shown in correct space.
Hourly wage is used for hourly employees only.
Use only weekly wage for salaried personnel. 30 Name of first doctor. Be sure to include complete mailing address. Date employee completes Part I and Part II, not the date of injury. If State Classified employee, then list leave balance as of the date of injury.