COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS’ COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 EMPLOYEE SOCIAL SECURITY NUMBER STATEMENT OF WAGES - (FOR INJURIES OCCURRING ON and AFTER JUNE 24, 1996) - DATE OF INJURY PA BWC CLAIM NUMBER (IF KNOWN) - - MONTH EMPLOYEE Name Last Name Address Address YEAR EMPLOYER First Name DAY Address Address City/Town City/Town State Telephone ( County Zip State Zip County ) Telephone ( ) FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self insured) CONCURRENT EMPLOYMENT ONLY Name Check if ■ Primary Employer OR ■ Concurrent Employer Address Address City/Town Telephone ( State ) SEE REVERSE SIDE FOR INSTRUCTIONS Zip 494C 0404 Bureau Code Claim # FEIN Computation: Compute the appropriate item below for the employee to determine their average weekly wage. Wages Weekly Board/Lodging 1. If wages are fixed by the week: Weekly Federal Reported Gratuities Annual Bonus, Incentive or Vacation Ö 52 + + 2. If wages are fixed by the month: x12Ö52 + + + =$ 3. If wages are fixed by the year: Ö52 + + =$ + + Average Weekly Wage =$ 4. If paid in another manner, then complete the following for each of the last four consecutive periods of 13 calendar weeks preceding the injury. From To Wages Board/Lodging Federal Reported Gratuities Period Weekly Wage 1st Period + + Ö 13 = $ 2nd Period + + Ö 13 = $ 3rd Period + + Ö 13 = $ 4th Period + + Ö 13 = $ (Sum of Three Highest Periods) = $ Ö52=$ Annual Bonus, Incentive and Vacation $ Sum of the highest three period weekly averages = $ (Weekly Bonus, etc.) Ö3+$ (Weekly Bonus, etc.) Average Weekly Wage = $ 5. If the employee has not been employed by the employer for at least three consecutive periods of 13 calendar weeks in the 52 weeks preceding the injury, use #4 above and put in the wages for any completed period(s) of 13 weeks immediately preceding the injury and average the total amounts................................................................................................................... = $ 6. If the employee worked less than a complete period of 13 calendar weeks and does not have fixed weekly wages: hourly wage rate $ x the number of hours the employee was expected to work per week under the terms of employment gratuities $ =$ + weekly board/lodging of $ + (annual bonus, incentive or vacation payÖ52) $ + weekly federal reported .................................................... = $ 7. For seasonal occupations, the average weekly wage is one-fiftieth of the total wages earned from all occupations during the 12 months immediately preceding the injury. Twelve months prior earnings $ + weekly board/lodging $ + weekly federal reported gratuities $ Ö50 = $ ........................................... = $ 8. If the calculation in #7, or any other calculation above, does not fairly ascertain the earnings of the employee, the period of calculation is extended to give a fair calculation of their average weekly wage. Show this calculation here OR use the space below to show calculations for concurrent employment. ___________________________________________________________________________________________________ = $ COMPENSATION PAYABLE PER WEEK: = $ Name of Employer/Insurer Representative LIBC-494C REV 4-04 (Page 1) INSTRUCTIONS NOTICE TO EMPLOYER: THE ORIGINAL MUST BE FILED WITH THE NOTICE OF TEMPORARY COMPENSATION PAYABLE, NOTICE OF COMPENSATION PAYABLE OR AGREEMENT FOR COMPENSATION FOR DISABILITY OR PERMANENT INJURY AND SENT TO THE BUREAU. A COPY MUST BE SENT TO THE INJURED EMPLOYEE. On this form, you must use the calculation method appropriate to which the employee is paid. For all calculation methods, room and board received from the employer and gratuities reported for federal tax purposes are included in determining the average weekly wage. Bonus, incentive or vacation payments earned on an annual basis are divided by 52, and the amount is included in the average weekly wage as if earned from the employer liable for workers’ compensation. In calculating the average weekly wage, do not include amounts deducted by the employer under the contract of hiring for labor furnished or paid for by the employer and necessary for the performance of such contract by the employee, deductions from wages due the employer for rent and supplies necessary for the employee’s use in the performance of their work, and employer-paid fringe benefits, including, but not limited to, contributions to a retirement pension, health and welfare, life insurance, social security or any other plan to an employee or their dependents. If using #4 and less than three completed periods, average the total period weekly wages and use #5 to list the average weekly wage. Also, if any periods are not complete, do not list any information for the period. The resulting “average weekly wage” is used to determine the amount of weekly compensation wage-loss benefits payable under Section 306 of the Workers’ Compensation Act. A chart is available from the Bureau of Workers’ Compensation to aid in determining the weekly compensation rate. To receive a copy, please call (717) 772-0618 or go online at www.state.pa.us; PA Keyword: “workers comp”. CONCURRENT EMPLOYMENT 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. Submit these forms together. Using #8 on the Primary Employer’s form only (employer with whom the injury occurred): show the addition of the average weekly wages from all employers, show the combined average weekly wage to the right of the equal sign, and show the appropriate workers’ compensation rate. Check the Primary Employer box. Check the Concurrent Employer box for all other employers. NOTE: Insurers and self-insured employers will use the information on non-affected continuing employments in determining an adjustment of the weekly workers’ compensation rate and report it on the Supplemental Agreement For Compensation For Disability or Permanent Injury Form. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-494C REV 4-04 (Page 2)