Statement Of Wages (For Injuries Occurring On Or Before June 23 1996) {LIBC-494A}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION STATEMENT OF WAGES002 (FOR INJURIES OCCURRING002 ON OR BEFORE JUNE 23, 1996)002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) First name Last name Address Address City/Town State ZIP Telephone FEIN Contact NAIC code or Insurer code Insurer/TPA Claim # DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN CONCURRENT EMPLOYMENT ONLY Check if Primary employer OR Concurrent employer INSTRUCTIONS The Statement of Wages must be clearly completed in accordance with the Pennsylvania Workers222 Compensation Act and uploaded in accordance with the provisions of the EDI Implementation guide when submitting certain EDI transactions. A copy must be sent to the injured employee. Pennsylavania Workers222 Compensation Act. A chart is available from the Bureau of Workers222 Compensation to aid in determining the weekly compensation rate, online at www.dli.state.pa.us CONCURRENT EMPLOYMENT If the employee had more than one employer at the time of injury, a separate Statement of Wages form must be completed for each employer. Submit these forms together. Using #7 on the Primary Employer222s form only (employer with whom the injury occurred), show the addition of the average weekly wages from all employers, show the combined average weekly wage to the right of the equal sign and show the appropriate workers222 compensation rate. Check the Primary employer box and the Concurrent employer box for all other employers. American LegalNet, Inc. www.FormsWorkFlow.com 0 0 0 Computation: Compute the appropriate items below for the employee. The highest result of the computations is used to determine the average weekly wage to establish the basis for workers222 compensation payments. (a)003 Week..................................................................$002 (b)003 Month $X 12 367 52 = $ (c)003 Year $367 52 = $ each of the four 13-week periods prior to the date of injury: BOARDING * DAYS FROM THROUGH WAGES LODGING * GRATUITIES ** TOTAL WORKED 1st Period $ $ $ $002 2nd Period002 $ $ $ $002 3rd Period002 $ $ $ $002 4th Period002 $ $ $ $ *Include at actual value of board and/or lodging**Include if employee receives at least one-third of wages in tips or gratuities (a)003 Using the highest 13-week period from above:002 $ 002divided by 13-weeks..........................................................................................= $002 (b)003 Last two completed by 13-week periods002 $ 002total wages divided by total days employee worked multiplied by 5 ...................=$002 3.003 If employed less than one 13-week period: $ total wages divided by total days employee worked times total days worked by other 002 e mployees in a similar occupation fo r the quarter immediately preceding the injur y divided by 13 .........= $002 4.003 If occupation is exclusively seasonal:$ 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 September, October through December): 5.003 $total wages earned with the same employer during the two complete calendar quarters divided002 by the 002number of days worked for the employer during that period multiplied by 5 .....................= $002 002002immediately preceding the date of injury is $divided by 13...............................................= $002 7.003 BASED ON ABOVE INFORMATION, THE HIGHEST AVERAGE WEEKLY WAGE FOR INJURED EMPLOYEE IS .... = $ COMPENSATION PAYABLE: $ PER WEEK Employer/Defendant Representative222s signature Employer/Defendant Representative222s name (typed/printed) Telephone 77 P.S. 2471039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. 2474117 (relating to insurance fraud). Employer Information Claims Information Services Email Services toll-free inside PA: 800.482.2383 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 Hearing Impaired *494A*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com