AVERAGE WEEKLY WAGE WORKSHEET WC# The definition of wages can be found in 8-40-201(19), C.R.S. Calculation of average weekly wage can be found in 8-42-102(2), C.R.S. Use earnings immediately prior to the date of injury. Employee Name Time Period used for calculations: From___/___/___ TO ___/___/___ If completed by the adjuster: Information received from: Name WAGES 1. 2. 3. 4. 5. 6. 7. 8. Title On Date (Choose one from lines 1 through 7, then add other wages from lines 8 - 10, if applicable) TOTALS Hourly wage $_______ x average hours/week _____ =............................................ Daily rate $_________x # of days (and fractions of days) in a week that employee worked (or would have worked, but for the injury) ______ =................................... Weekly wage $________ = ....................................................................................... Bi-Weekly wage (every other week) $_________÷ 2 = .......................................... Semi-Monthly wage $_______ x 24 ÷ 52 =............................................................. Monthly wage $_______ x 12 ÷ 52 = ...................................................................... Yearly wage $_________ ÷ 52 = ............................................................................. Average weekly value = Total amount earned with this employer in the 12 months immediately preceding injury $______________ ÷ # of weeks (and fractions of weeks) worked ________ = .................................................................. Rate per mile $_______x average # of miles per day driven in service of the employer 60 days preceding the injury __________ = daily rate $__________ x days (and fractions of days) per week worked ______ = .......................................... (Attach explanation) Average weekly value $__________ = ..................................................................... Enter amounts from 1 - 7, plus any amounts in 8 - 10 .............................................. SS# Carrier # Hourly (exclude overtime) Daily (per diem)..................... Weekly................................... Bi-Weekly.............................. Semi-Monthly ........................ Monthly.................................. Yearly .................................... Piecework or Commission ..... 9. Mileage (only if mileage is a form of salary) ....................... Other (wages not addressed above) .................................... Total Wages ........................... 10. 11. ADDITIONS TO WAGES (Use the same time period as stated above) 12. 13. 14. Overtime ................................ Tips ........................................ Total Additions ...................... Overtime rate $________ x # of overtime hours per week ________ = ................... Weekly amount reported to IRS $___________ = .................................................... Enter total of lines 12 + 13.................................................................... BENEFITS (If Discontinued During Disability) 15. Health Insurance Effective date benefit discontinued:_____________ Employee's monthly cost of continuing the employer's group plan or conversion to a similar or lesser plan = $__________ x 12 ÷ 52 = 16. 17. 18. Meals / Board Rent / Housing Total Benefits......................... Effective date benefit discontinued:______________ Weekly value $___________ =................................................................................. Effective date benefit discontinued: ______________ Monthly value $__________ x 12 ÷ 52 ............................................................... Enter total of lines 15 - 18 ......................................................................................... 19. TOTAL AVERAGE WEEKLY WAGE Enter total of lines 11 + 14 + 18 ................................................................................ Enter the number in line 19 on the Employer's First Report of Injury in the "Average Weekly Wage at Time of Injury" Box Completed by: ________________________________________________________Date__________________________ DK 1 Rev 05/06 1 American LegalNet, Inc. www.FormsWorkFlow.com Division of Workers' Compensation 633 17th Street, Suite 400 Denver, Colorado 80202-3626 303.318.8700 - The Average Weekly Wage worksheet may be reproduced as needed The Average Weekly Wage worksheet is provided by the Division of Workers' Compensation as a guideline in computing the Average Weekly Wage. It is intended as a desk aid worksheet and is not a required document. It may be used to document wage information received verbally. If the worksheet is completed by the employer, the final Average Weekly Wage amount on Line 19 of the worksheet should be inserted in the box, "Average Weekly Wage at Time of Injury," on the Employer's First Report of Injury form. Notice to Employer: The worksheet should be attached to the Employer's First Report of Injury form when submitted to your workers' compensation insurance administrator. If you have questions on completing this worksheet, contact your workers' compensation insurance administrator. Notice to Insurance Carrier or Self-Insured Employer: If you complete the worksheet with information provided by either the claimant or the employer, attach the worksheet to your position statement when filing with the Division. Also, state on the worksheet the name and title of the person providing wage information and the date the information was provided. If you receive the worksheet from the employer and only "the Average Weekly Wage at Time of Injury" box is completed in the wage information section of the Employer's First Report of Injury, attach the worksheet to the Employer's First Report of Injury form that is submitted to the Division of Workers' Compensation. DK 1 Rev 05/06 2 American LegalNet, Inc. www.FormsWorkFlow.com