Wage Chart {7A}

WAGE CHART EMPLOYER’S STATEMENT OF WAGE EARNINGS. This form is used by the Virginia Workers’ Compensation Commission to document an injured employee’s gross weekly earnings for the 52 weeks immediately preceding the date of their workplace accident. The form is typically completed by the employer or insurer and includes detailed entries for each week, such as the number of days worked and gross pay including overtime. It also captures the total value of any non-cash benefits, or “perquisites,” such as housing, meals, uniforms, utilities, or bonuses received by the employee. This information is critical in calculating the employee’s Average Weekly Wage (AWW) and Compensation Rate (CR), which determine the amount of workers’ compensation benefits the employee may be entitled to. Special notations are made if the employee missed more than seven consecutive calendar days, and instructions are provided for how to handle employees who have not worked a full year or who are paid bi-weekly. The form must be signed by the employer or insurer, and a detailed set of filing and calculation instructions are included to ensure accurate submission. www.FormsWorkflow.com