The Commonwealth of Massachusetts Department of Industrial Accidents FORM 127 DIA USE ONLY 600 Washington Street – 7th Floor, Boston, Massachusetts 02111 Info. Line 800 323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia AVERAGE WEEKLY WAGE COMPUTATION SCHEDULE Print or Type 1. Employer’s Name and Address: 2. Insurer’s Case File #: 3. DIA Board # (if known): 5. # of dependent children: 4. Employee’s Name and Address: 6. # of other dependents: 7. Date of Injury (mm/dd/yyyy): 8. Date of Disability (mm/dd/yyyy): 9. Date of Employment (mm/dd/yyyy): 10. Has employee been certified by U.S. Veterans Administration for any type of disability? Yes No Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident. If the injured employee has worked for less than 52 weeks, report wages from the time worked and, for the remaining weeks on this schedule, substitute wages of a fellow employee in the same class of employment who has worked for one year or more. Year: 11. Week Week Ending No. Month Day Year: Year: Gross Amount Before Taxes Week No. Week Ending Month Gross Amount Before Taxes Day 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 12. Was room furnished to the employee? Yes Week No. Gross Amount Before Taxes Week Ending Month Day 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Total: 13. If tips or other benefits were earned, describe and state value per week: No THIS IS A TRUE COPY OF THE PAYROLL RECORD OF THE ABOVE NAMED EMPLOYEE OR FELLOW EMPLOYEE IN THE SAME CLASS OF EMPLOYEMENT 14. Name of Fellow Employee (if applicable): 15. Employer/Preparer Signature: Make any comments on the reverse side of this form or on a separate sheet. 16. Date Signed (mm/dd/yyyy): American LegalNet, Inc. www.USCourtForms.com Form 127 - Created 8/2005 Reproduce as needed. Comments: American LegalNet, Inc. www.USCourtForms.com