Massachusetts > Workers Comp
Average Weekly Wage Computation Schedule 127 - Massachusetts
| Average Weekly Wage Computation Schedule Form. This is a Massachusetts form and can be used in Workers Comp . |
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FORM 127 The Commonwealth of Massachusetts Department of Industrial Accidents 600 Washington Street 7th Floor, Boston, Massachusetts 02111 Info. Line 800 323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia DIA USE ONLY AVERAGE WEEKLY WAGE COMPUTATION SCHEDULE Print or Type 1. Employer's Name and Address: 2. Insurer's Case File #: 3. DIA Board # (if known): 4. Employee's Name and Address: 5. # of dependent children: 6. # of other dependents: 7. Date of Injury (mm/dd/yyyy): 8. Date of Disability (mm/dd/yyyy): 9. Date of Employment (mm/dd/yyyy): 10. Has employee been certified by U.S. Veterans Administration for any type of disability? Yes No Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident. If the injured employee has worked for less than 52 weeks, report wages from the time worked and, for the remaining weeks on this schedule, substitute wages of a fellow employee in the same class of employment who has worked for one year or more. Year: 11. Week Week Ending No. Month Day Year: Gross Amount Before Taxes Week No. Week Ending Month Day Gross Amount Before Taxes Week No. Year: Week Ending Month Day Gross Amount Before Taxes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 12. Was room furnished to the employee? Yes No 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Total: 13. If tips or other benefits were earned, describe and state value per week: THIS IS A TRUE COPY OF THE PAYROLL RECORD OF THE ABOVE NAMED EMPLOYEE OR FELLOW EMPLOYEE IN THE SAME CLASS OF EMPLOYEMENT 14. Name of Fellow Employee (if applicable): 15. Employer/Preparer Signature: 16. Date Signed (mm/dd/yyyy): Make any comments on the reverse side of this form or on a separate sheet. American LegalNet, Inc. www.USCourtForms.com Form 127 - Created 8/2005 Reproduce as needed. Comments: American LegalNet, Inc. www.USCourtForms.com
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