Rev. 1/08 Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 Fax: 304.941.1294 Employer’s Report of Wages EMPLOYERS: PLEASE SUBMIT THIS FORM WITH THE EMPLOYER’S REPORT OF INJURY Claimant benefit rates are based on both the daily rate of pay and the four quarters of wages preceding the date of injury, whichever is most favorable to the claimant. In the past we obtained this information from the Bureau of Employment Programs. As a private insurance company we no longer have access to this data; therefore, we will begin collecting this information from the employer. The wage information is necessary in any claim where an indemnity payment is anticipated to ensure the claimant receives the appropriate benefit rate. POLICYHOLDER INFORMATION Policyholder Name: Policy Number: Telephone Number: Address: City: State: Zip: CLAIMANT INFORMATION Claimant Name: Claim Number: DOI: SSN: Instructions for Calculating and Reporting Wages The following calculation should be used when an employee routinely works 40 hours a week. Calculate the hourly rate X 40 hours worked / by 5 = daily rate of pay The daily rate of pay should include any tips, commissions or other remuneration such as cost of lunches, uniforms, gratuities, etc. The following calculation should be used when an employee works shifts in excess of eight hours per day, but less than five days per week: Calculate the hourly rate X # of hours worked for a normal work week / 5 = daily rate of pay The following calculation should be used when an employee routinely works overtime: Calculate the number of regular hours X the regular hourly rate and calculate the overtime hours X the overtime rate. These amounts will be added together to obtain the average daily rate of pay to be reported by the employer. The employer must report the quarterly earnings for the four preceding quarters prior to the date of injury. Example: for a claim with a date of injury of April 2007, wages should be reported as follows: • the first quarter of 2007(January, February, March 2007) • the second quarter of 2006 (April, May, June 2006) • the third quarter of 2006 (July, August, September 2006) • the fourth quarter of 2006 (October, November, December 2006) Part-Time Daily Rate of Pay: Hourly Rate of Pay: Full-Time Hours Worked per 25 hours or less First Quarter Jan. Feb. Mar. / $ $ $ Second Quarter Apr. May June/ $ Week: Third Quarter July Aug. Sept./ $ Does the employer offer a wage continuation plan to this employee? Yes Does the claimant receive wages from other employment? Yes Fourth Quarter Oct. Nov. Dec./ $ No No Printed Name: Signature: Title: Date: American LegalNet, Inc. www.FormsWorkFlow.com