Workers comp pay checklist
A printable from Workers comp pay. Fill it in by hand. Nothing you write is collected by this website.
Printable checklist
My workers' comp pay tracker
Date of injury: __________ Date I told my employer: __________ Claim number: __________
My average weekly pay before the injury (include overtime and cash): $__________
Two thirds of that: $__________ (2026 minimum $264.61, maximum $1,764.11)
Temporary disability checks
| Check date | Weeks it covers | Amount | On time? (every 2 weeks) |
|---|---|---|---|
Key dates
- First check due (14 days after employer knew): __________
- Week 104 of temporary disability falls on about: __________
- Doctor's permanent and stationary report date: __________
- First permanent disability check due (14 days after last TD check): __________
- Voucher served on: __________ Return to Work Supplement deadline (1 year): __________
Before I sign any settlement
- I talked to Information and Assistance (1-800-736-7401) or a lawyer
- I know whether it ends my future medical care
From Workers comp pay. Facts checked October 21, 2026. Free information, not legal or medical advice.