Pennsylvania > Workers Comp
Statement Of Wages (For Injuries Occurring On Or Before June 23 1996) LIBC-494A - Pennsylvania
| Statement Of Wages (For Injuries Occurring On Or Before June 23 1996) Form. This is a Pennsylvania form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION COURT 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 COUNTY .OF. . . . . . . . . . .FOR .INJURIES OCCURRING. ......... .. ... ................. (TOLL FREE) 800-482-2383 STATEMENT OF WAGES Social Security Number: Date of Injury: MM DD YYYY (IF KNOWN) . . . . . .PA BWC Claim Number: ... ON OR BEFORE JUNE 23, 1996 : Index No. Employer Name Street 1 Employee First Name Street 1 Street 2 Last Name : : : Calendar No. Plaintiff(s) -againstState Zip Code Street 2 City/Town JUDICIAL SUBPOENA State FEIN Zip Code City/Town : THE FOLLOWING WAGE INFORMATION MUST BE COMPLETED IN ACCORDANCE WITH SECTION 309 OF THE PENNSYLVANIA : WORKERS' COMPENSATION ACT, THE ORIGINAL ATTACHED TO NOTICE OF COMPENSATION PAYABLE OR AGREEMENT FOR COMPENSATION FOR DISABILITY OR PERMANENT INJURY AND SENT TO THE BUREAU. A COPY IS TO BE SENT TO EMPLOYEE. .. . . . . . . . . . . . . . . . . . . items . . . . . . . . . . . . . . . . . . . . Computation: . . . Compute.the.appropriate . . . . . below for. the.employee. .The. highest result of the computations is used to determine the average weekly wage to be used to establish the basis for workers' compensation payments. 1. If wages fixed by: $ (a) Week THE PEOPLE OF THE STATE OF NEW YORK (b) Month $ times 12 divided by 52 = $ (c) Year $ TO 2. divided by 52 = $ 494A 1297-1 Defendant(s) : If wages fixed by day, hour, or output, including overtime and bonus, then complete the following for each of the four 13-week periods prior to the date of injury: FROM GREETINGS: TO $ WAGES $ BOARD* LODGING* $ GRATUITIES** $ TOTAL. DAYS WORKED 1st Period 2nd Period WE COMMAND YOU, that all business and $ excuses being laid aside, you and each of you attend before $ $ $ , at the Court $ $ $ $ located at County of $ $ $ $ 4th Period in room , on theInclude at actual value of board and/or lodgingat day of , 20 , o'clock in the noon, and at any recessed * ** Include employee receives at least one-third this action or the part or adjourned date, to testify and ifgive evidence as a witness in of wages in tipson gratuities of the the 3rd Period Honorable (a) Using the highest 13-week period from above: $ divided by 13 weeks =$ (b) Last two completed 13-week comply with this subpoena is punishable as a contempt of court and will make you liable to Your failure to periods: $ the party on whose behalf this subpoena was issued days employee worked multiplied by all damages sustained as a total wages divided by total for a maximum penalty of $50 and 5 =$ 3. result of than one 13-week period: If employed lessyour failure to comply. $ total wages divided by total days employee worked times total days worked Witness, Honorable , one divided by 13 by other employees in a similar occupation for the quarter immediately preceding the injury of the Justices of the$ = Court is exclusively seasonal: in County, day of , 20 4. If occupation $ total wages from all occupations during 12 calendar months preceding injury divided by 50 =$ For the following two methods, use calendar quarters (i.e. January through March, April through June, July through (Attorney must sign above and type name below) September, October through December): total wages earned with the same employer during the last two complete calendar quarters $ 5. 6. divided by the $ number of days worked for the employer during that period multiplied by 5 Attorney(s) for wages under Section 309(f) are computed using the calendar quarters as defined above. divided by 13 =$ The highest calendar quarter wages received in the first four of the last five completed calendar quarters immediately preceding the date of injury is $ =$ $ PER WEEK BASED ON ABOVE INFORMATION, THE HIGHEST AVERAGE WEEKLY WAGE FOR INJURED EMPLOYEE IS Office and P.O. Address COMPENSATION PAYABLE: $ Name of Insurer or Third Party Administrator (if self-insured): Name of Employer/Insurer Representative: Phone Bureau Code Telephone No.: Facsimile No.: Any individual filing misleading or incomplete information knowingly and withE-Mail Address: is in violation of Section 1102 of the intent to defraud Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of Mobile Tel. No.: Signature of Employer/Insurer Representative: 1994. LIBC-494A REV 12-97 American LegalNet, Inc. www.USCourtForms.com
|
|||||||
