PART E WAGE-LOSS WORKSHEET #1

 

Part E Wage-Loss Worksheet - # 1

Employee’s Name:

     

File #:

     

Claims Examiner’s Name:

     

 

District Office:

     

Calculate Average Annual Wage

1.

Enter date of first wage-loss (MM/DD/YYYY)

     

2.

Enter the total number of quarters (of the 12 quarters prior to but not including the quarter of the date entered in line 1) in which the employee was employed (Earned more than $700 in constant 2005 dollars)

     

3.

Enter the combined total of wages of the quarters (quarter in which the employee was employed) included on Line 2.

     

4.

Divide line 3 by line 2.

     

5.

Multiply line 4 by 4.  This is the Average Annual Wage.