Wage Chart {7A}

Wage Chart Employer222s Statement of Wage Earnings Virginia Workers222 Compensation Commission 333 E. Franklin St., Richmond, Virginia 23219 The boxes Reserved VWC File Number to the right use of the insurer. Insurer Claim Number Employee Address Name of Employee Date of Accident Date of Hire Employer Address Name of Employer Employee222s Social Security Number PLEASE REFER TO THE FILING INSTRUCTIONS PRINTED ON THE BACK OF THIS FORM Week No. Week Ending Date Days Worked Gross amount paid, including overtime Week No. Week Ending Date Days Worked Gross amount paid, including overtime Week No. Week Ending Date Days Worked Gross amount paid, including 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 18 36 Value of perquisites for entire year: Total gross earning $ Total weeks worked Bonuses $ Electricity $ Meals/Lodging $ Water $ Total value of perquisites $ Meals Only $ Telephone $ Temporary Lodging $ Uniforms $ House Rent $ Laundry $ Total earnings & perquisites $ Tip Income $ Wage Chart VWC Form No. 7A (rev. 07-01-06) VWC use only: AWW: CR: INSURER OR EMPLOYER (include name & signature) Date Telephone number American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS (Instructions Updated 09/01/07) Wage Chart VWC Form No. 7A The information at the top right of the form should be provided by the insurer. Please note that the insurer code refers to the five-digit numeric code assigned by The National Counsel on Compensation Insurance (NCCI). Self-insured employers are assigned a similar five-digit code number by the Virginia Workers222 Compensation Commission. Illegible forms will be returned to the insurer. How to complete the Wage Chart: Indicate gross weekly earnings for the 52 weekly periods immediately preceding the date of accident. Note that these earnings are GROSS earnings and include overtime and tips, before any deductions aremade for taxes or Social Security. If there were any perquisites, please list the TOTAL valueseparately at the bottom of the chart. If an injured employee lost more than seven consecutive calendar days, although not in the same week,these periods should be noted on the Wage Chart (VWC Form No. 7-A) using an asterisk in theWeek No. column and are not to be counted in the calculations. Va. Code 247 65.2-101. If injured employee has worked less than 12 months, the earnings for the time worked should be used.The earnings for a similar employee may be used if the employee has worked less than 60 days. How to calculate the Wage Chart: If a full year222s wage information has been provided covering the 52 week period prior to the dateof accident:-determine the total wages earned, including yearly perquisites;-divide the total wages earned for this period by 52;-the sum will be the average weekly wage.If a full year222s wage information has not been provided covering the 52 week period prior to thedate of accident:-determine the total wages earned, including yearly perquisites;-divide the total wages earned by the number of weeks wages were earned (Note: if warranted,the weeks can be converted into days and calculated on that basis);-the sum will be the average weekly wage.If the form is completed on a bi-weekly basis:-determine the total wages earned, including yearly perquisites;-divide the total wages earned by the number of weeks worked (employeepaid 26 times a year represents 52 weeks of wages);-the sum will be the average weekly wage. Samples of properly completed wage chart(s) are available through the Commission222s Website atwww.vwc.state.va.us under the forms menu.For questions or assistance with completing this form, please contact theCommission222s Toll-Free number at (1-877) 664-2566. American LegalNet, Inc. www.FormsWorkFlow.com