Quick Reference Guide

VirginiaWorkers’ Compensation Commission Claims Services Reference Material

Wage Chart Employer’s Statement of Wage Earnings

The boxes

Reserved

VWC File Number

to the right are for the use of the Insurer Code

000-00-00

Insurer Location

insurer.

Virginia Workers’ Compensation Commission 333 E. Franklin St., Richmond, Virginia 23219

Insurer Claim Number

Employee

Address

Name of Employee John P. Hurtworker

Date of Accident

Date of Hire

07/10/2004

Employer

Address

Name of Employer

Employee’s Social Security Number

Virginia Workers' Compensation Commission

xxx-xx-xxxx

PLEASE REFER TO THE FILING INSTRUCTIONS PRINTED ON THE BACK OF THIS FORM

Week No.

Week Ending Date

Days Worked

Gross amount paid, including overtime

Week No.

Week Ending Date

Days Worked

Gross amount paid, including overtime

Week No.

Week Ending Date

Days Worked

Gross amount paid, including overtime

6

11/21/03

240.00 200.00 200.00 200.00 200.00 200.00 200.00 200.00 160.00 280.00 220.00 220.00 220.00 220.00 220.00 176.00

03/26/04 04/02/04 04/09/04

6 5 5

5

240.00 200.00 200.00 200.00 200.00 200.00 160.00 200.00 200.00 200.00 200.00 200.00 160.00 296.00 200.00 200.00 200.00 200.00

07/18/03

200.00 240.00 200.00 200.00 200.00 240.00 200.00 200.00 200.00 200.00 200.00 200.00 200.00 288.00 294.00 200.00 200.00 200.00

1

19

37

07/25/03 6

11/28/03 5 12/05/03 5 12/12/03 5

2

20

38

08/01/03

5 5

3

21

39

04/16/04 5 04/23/04 5

08/08/03

4

22

40

EXAMPLE

08/15/03 5 08/22/03 6

12/19/03 12/26/03 01/02/04 01/09/04 01/16/04 01/23/04 01/30/04 02/06/04

5

5

23

41

5

04/30/04 05/07/04 05/14/04 05/21/04 05/28/04 06/04/04

5 5 5 4

6

24

42

Date of injury: 7/10/04

08/29/03

5

4

7

25

43

09/05/03 5

5 5

8

26

44

09/12/03 09/19/03 09/26/03 10/03/03

5

Date range you can use: 7/10/03 to 7/09/04 STEPS: 1. Add up all applicable weeks 2. Add any perquisites to total (if any) 3. Divide by the number of weeks used This example: $10,874.00 + $500 = $11,374.00 ÷ 52 weeks= $218.73 AWW

9

27

45

6 5

5 5 5 4

5 5 5

10

28

46

11

29

47

06/11/04 5

12

30

48

02/13/04

10/10/03 5

06/18/04 06/25/04

5

13

31

49

10/17/03

02/20/04 6

6

5

14

32

50

10/24/03 6

02/27/04 03/05/04

5 5

07/02/04 5 07/09/04 4

15

33

51

10/31/03

5

16

34

52

03/12/04 5

11/07/03 5

Totals

17

35

$10,874.00

11/14/03

03/19/04

5

5

18

36

52

Total gross earning $ ____________ 10,874.00

Value of perquisites for entire year:

Total weeks worked _______

500.00

Bonuses $

Electricity $ _______

500.00

Total value of perquisites $_____________

Meals/Lodging $ Meals Only $ Temporary Lodging $

Water $

VWC use only:

Telephone $ _______ Uniforms $ _______

Total earnings & perquisites $ _____________ 11,374.00

House Rent $

Laundry $

AWW: ________ CR: ________

T ip Income $ ________

INSURER OR EMPLOYER (include name & signature)

Date

Telephone number

Wage Chart VWC Form No. 7A (rev. 07-01-06)

2