DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION STATEMENT OF WAGES (FOR INJURIES OCCURRING ON OR AFTER JUNE 24, 1996) DATE OF INJURY WCAIS CLAIM NUMBER EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER EMPLOYEE First name Last name Date of birth Address Address City/Town County MM DD YYYY EMPLOYER Name Address Address City/Town County State Telephone ZIP Telephone FEIN State ZIP INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town County Telephone Contact NAIC code Insurer/TPA claim # or Insurer code FEIN State ZIP CONCURRENT EMPLOYMENT ONLY Check if Primary employer OR Concurrent employer INSTRUCTIONS The Statement of Wages must be clearly completed in accordance with the Pennsylvania Workers' Compensation Act and uploaded in accordance with the provisions of the EDI Implementation guide when submitting certain EDI transactions. A copy must be sent to the injured employee. The "average weekly wage" is used to determine the amount of weekly compensation wage-loss benefits payable under the Pennsylavania Workers' Compensation Act. A chart is available from the Bureau of Workers' Compensation to aid in determining the weekly compensation rate, online at www.dli.state.pa.us 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 for the Primary employer and the Concurrent employer box for all other employers. American LegalNet, Inc. www.FormsWorkFlow.com LIBC-494C REV 04-18 (Page 1) Computation: Compute the appropriate items below for the employee to determine the average weekly wage. Weekly Board/ Lodging Weekly Federal Reported Gratuities Annual Bonus, Incentive or Vacation Average Weekly Wage Wage 1. 3. 4. If wages are fixed by the week: If wages are fixed by the year: � 52 + x 12 � 52 + + + + + + + + =$ =$ =$ 2. If wages are fixed by the month: If paid in another manner, then complete the following for each of the last four consecutive periods of 13 calendar weeks preceding the injury. Federal Reported Gratuities From Through Wages Board/Lodging Period Weekly Wage 1st Period 2nd Period 3rd Period 4th Period Annual bonus, incentive and vacation $ Sum of the highest three period weekly averages = $ 5. + + + + � 52 = $ �3+$ + + + + (Weekly bonus, etc) � 13 � 13 � 13 � 13 =$ =$ =$ =$ =$ Average Weekly Wage (Sum of three highest periods) (Weekly bonus, etc) =$ 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 periods(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 =$ + weekly board/lodging of $ + weekly federal reported gratuities $ + (annual bonus, incentive or vacation pay � 52) $ ..................................................................................... = $ 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 $ � 50 = $ + weekly board/lodging $ + weekly federal reported gratuities $ ................................................................ = $ 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: =$ 7. 8. Employer/Defendant Representative's signature Telephone Employer/Defendant Representative's name (typed/printed) Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act, 77 P.S. �1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. �4117 (relating to insurance fraud). Employer Information Services 717.772.3702 Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447 Hearing Impaired PA Relay 7-1-1 Email ra-li-bwc-helpline@pa.gov Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-494C REV 04-18 (Page 2) *494C* American LegalNet, Inc. www.FormsWorkFlow.com