Wage Chart Form. This is a Virginia form and can be use in Workers Compensation.
Tags: Wage Chart, 7A, Virginia Workers Compensation,
Wage Chart The boxes to the right are for the use of the insurer. Employer’s Statement of Wage Earnings Virginia Workers’ Compensation Commission 1000 DMV Drive Richmond VA 23220 Employee Reserved VWC File Number Insurer Code Insurer Location Insurer Claim Number Address Name of Employee Date of Accident Employer Date of Hire Address Name of Employer Employee’s Social Security Number PLEASE REFER TO THE FILING INSTRUCTIONS PRINTED ON THE BACK OF THIS FORM Week No. Week Ending Date Days Worked Gross amount paid, including overtime Week No. Week Ending Date Days Worked Gross amount paid, including overtime Week Ending Date Week No. 1 19 20 38 3 21 39 4 22 40 5 23 41 6 24 42 7 25 43 8 26 44 9 27 45 10 28 46 11 29 47 12 30 48 13 31 49 14 32 50 15 33 51 16 34 52 17 35 18 Gross amount paid, including overtime 37 2 Days Worked 36 Value of perquisites for entire year: Bonuses $ Meals/Lodging $ Meals Only $ Temporary Lodging $ House Rent $ Tip Income $ ________ Electricity $ _______ Water $ Telephone $ _______ Uniforms $ _______ Laundry $ INSURER OR EMPLOYER (include name & signature) Totals Total gross earning $ ____________ Total weeks worked _______ Total value of perquisites $_____________ VWC use only: Total earnings & perquisites $ _____________ Date AWW: ________ CR: ________ Telephone number Wage Chart VWC Form No. 7A (rev. 07-01-06) American LegalNet, Inc. www.FormsWorkflow.com FILING INSTRUCTIONS (Instructions Updated 09/01/07) Wage Chart VWC Form No. 7A The information at the top right of the form should be provided by the insurer. Please note that the insurer code refers to the five-digit numeric code assigned by The National Counsel on Compensation Insurance (NCCI). Self-insured employers are assigned a similar five-digit code number by the Virginia Workers’ Compensation Commission. Illegible forms will be returned to the insurer. How to complete the Wage Chart: • Indicate gross weekly earnings for the 52 weekly periods immediately preceding the date of accident. • Note that these earnings are GROSS earnings and include overtime and tips, before any deductions are made for taxes or Social Security. If there were any perquisites, please list the TOTAL value separately at the bottom of the chart. • If an injured employee lost more than seven consecutive calendar days, although not in the same week, these periods should be noted on the Wage Chart (VWC Form No. 7-A) using an asterisk in the Week No. column and are not to be counted in the calculations. Va. Code § 65.2-101. • If injured employee has worked less than 12 months, the earnings for the time worked should be used. The earnings for a similar employee may be used if the employee has worked less than 60 days. How to calculate the Wage Chart: • If a full year’s wage information has been provided covering the 52 week period prior to the date of accident: - determine the total wages earned, including yearly perquisites; - divide the total wages earned for this period by 52; - the sum will be the average weekly wage. • If a full year’s wage information has not been provided covering the 52 week period prior to the date of accident: - determine the total wages earned, including yearly perquisites; - divide the total wages earned by the number of weeks wages were earned (Note: if warranted, the weeks can be converted into days and calculated on that basis); - the sum will be the average weekly wage. • If the form is completed on a bi-weekly basis: - determine the total wages earned, including yearly perquisites; - divide the total wages earned by the number of weeks worked (employee paid 26 times a year represents 52 weeks of wages); - the sum will be the average weekly wage. • Samples of properly completed wage chart(s) are available through the Commission’s Website at www.vwc.state.va.us under the forms menu. • For questions or assistance with completing this form, please contact the Awards Unit using the Commission’s Toll-Free number at (1-877) 664-2566. American LegalNet, Inc. www.FormsWorkflow.com