Virginia > Workers Compensation
Wage Chart 7A - Virginia
| Wage Chart Form. This is a Virginia form and can be used in Workers Compensation . |
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The boxes Reserved VWC File Nu m ber Wage Chart at the right Employers Statement of Wage Earnings are for the use of the Insurer Code Insurer Location Virginia Workers Compensation Commission insurer . 1000 DMV Drive Richmond VA 23220 Insurer Claim Number E mploy ee Address Name of Employee Date o f Accident E mploy er Ad dress Name of Employer Employees Social Security Number Instructions: Indicate gross weekly earnings for the52 weekly periods immediatelypr eceding the date of accident. If injured employee has worked less than 12 months, the earnings for the time worked should be used. The earnings for a similar employees may be used if the employee has worked less than 60 day s. Note that these earnings are GROSS earnings and include overtimnd e atips, before any deductions are made for taxes or Social Security. If there were any perquisites, pleaseth liste T OTAL value separately at the bottom of the ch. art Week Week Days Gross amount Week Week Ending Days Gross amount Week Week Ending Days Gross amount No. Ending Worked paid, including No. Date Worked paid, including No. Date Worked paid, including Date overtime overtime overtime 1 19 37 2 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 Totals 18 36 Value of perquisites for entire year: To tal g ross earning $ ____________ Total weeks worked _______ Bonuses $ Electricity $ _______ Meals/Lodging $ Water $ To tal value of perquisites $_____________ Meals Only $ Telep hone $ _______ VWC use only: Temporary Lodging $ Uniforms $ _______ House Rent $ Laundry $ Total earnings & perquisites $ ___________ __AWW: ________ Tip Income$ _ _______ CR: ________ INSURER OR EMPLOYER (include n ame & signature) Date Phone number Wage Chart V WC Form No. 7A (Rev 9-1-04) American LegalNet, Inc. www.USCourtForms.com
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