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Wage Calculation Form For Claims Agents Use Form. This is a Nevada form and can be use in Workers Comp.
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Tags: Wage Calculation Form For Claims Agents Use, D-5, Nevada Workers Comp,
WAGE CALCULATION FORM FOR CLAIMS AGENT'S USE
Injured Employee:
Date of Injury:
Social Security No.:
Claim No.:
Employer:
RE:
Insurer:
Third-Party Administrator:
Average Monthly Wage is defined in NAC 616C.420 through 616C.447.
The priorities for determining wage history are:
1. A 12-week history of earnings (84 days).
2. If a 12-week period of earnings is not representative of the injured employee's average monthly wage, a period of one year
or the full period of employment, if it is less than one year, may be used. A period of one year or the full period of
employment must be used if the average monthly wage would be increased. Divide by the number of days in the period.
3. If period of employment is more than four weeks, but less than twelve weeks, earnings from the date of hire will be used.
Divide by the number of days in the period.
4. If period of employment is less than four weeks, average monthly wage will be calculated by multiplying rate of pay on the
date of the accident or disease, by hours in employee's projected working schedule, divide by 7 and multiply by 30.44.
If other circumstances apply, see NAC 616C.435.
AVERAGE MONTHLY WAGE - Calculate AMW in the following manner:
Period of earnings: beginning date
Gross earnings
through end date
+ tips
in wage history
÷ by number of days
x 30.44 . . . . . . . . . . . . . . . . . . . = Average Monthly Wage:$
HOURLY RATE - Hourly rate of pay
projected to work per week
x number of hours
÷ 7 x 30.44 . . . . . . . = Average Monthly Wage:$
VALUE OF ROOM AND/OR BOARD
Room (Monthly Value)
....................................... $
Board (Monthly Value)
....................................... $
VALUE OF MEALS - If meals are provided by the employer, see NAC 616C.423(1)(p) and use the
following formula:
Amount for meals per day
to work per week
x number of days hired
=
÷ 7 x 30.44 . . . . . . . . . . . . . . . = Meals per Month:$
ADD applicable lines to obtain total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Average Monthly Wage:$
DAILY RATE - is to be calculated in the following manner:
Average Monthly Wage
Date
x 8 ÷ 12 ÷ 30.44 . . . . . . . . . . . . . . . . . .Daily Rate:$
Signature
D-5 (rev. 7/99)
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