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The DOL uses this form to determine employer compliance with the MSPA. This form enables us to calculate the correct compensation that may be due your injured employee.Information about Form W-2, Wage and Tax Statement, including recent updates, related forms and instructions on how to file. Instructions for Completing Employer's Statement of Wage Earnings (Form C-240). If the employee had more than one employer at the time of injury, a separate Statement of Wages form must be completed for each employer. Insurer Claim Number. Employee. Do not send this form to the Texas. Workers' Compensation Commission unless requested. 2, Request for Independent edical Examination. WCB-1, Employer's First Report of Occupational Injury or Disease.