Wage Calculation Form For Claims Agents Use {D-5}

WAGE CALCULATION FORM FOR CLAIMS AGENTS USE RE: Injured Employee: Date of Injury: Social Security No.: Claim No.: Employer: Insurer: Third-Party Administrator: Average Monthly Wage is defined in NAC 616C.420 through 616C.447. The priorities for determining wage history are: 1. A 12-week history of earnings (84 days). 2. If a 12-week period of earnings is not representative of the injured employees average monthly wage, a period of one year or the full period of employment, if it is less than one year, may be used. A period of one year or the full period of employment must be used if the average monthly wage would be increased. Divide by the number of days in the period. 3. If period of employment is more than four weeks, but less than twelve weeks, earnings from the date of hire will be used. Divide by the number of days in the period. 4. If period of employment is less than four weeks, average monthly wage will be calculated by multiplying rate of pay on the date of the accident or disease, by hours in employees projected working schedule, divide by 7 and multiply by 30.44. If other circumstances apply, see NAC 616C.435. AVERAGE MONTHLY WAGE - Calculate AMW in the following manner: Period of earnings: beginning date through end date Gross earnings + tips by number of days in wage history x 30.44 . . . . . . . . . . . . . . . . . . . = Average Monthly Wage:$ HOURLY RATE - Hourly rate of pay x number of hours projected to work per week 7 x 30.44 . . . . . . . = Average Monthly Wage:$ VALUE OF ROOM AND/OR BOARD Room (Monthly Value) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Board (Monthly Value) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ VALUE OF MEALS - If meals are provided by the employer, see NAC 616C.423(1)(p) and use the following formula: Amount for meals per day x number of days hired to work per week = 7 x 30.44 . . . . . . . . . . . . . . . = Meals per Month:$ ADD applicable lines to obtain total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Average Monthly Wage:$ DAILY RATE - is to be calculated in the following manner: Average Monthly Wage x 8 12 30.44 . . . . . . . . . . . . . . . . . .Daily Rate:$ Date Signature D-5 (rev. 7/99)