PART E WAGE-LOSS WORKSHEET #3

 

Part E Wage-Loss Worksheet - # 3

Employee’s Name: 

     

File #:

     

Claims Examiner’s Name:

     

District Office:

     

Determine Percentage of Wage-Loss and Award Amount

1.

Adjusted Earnings (from Worksheet # 2, line 4d).

     

2.

Divide line 1 by the Average Annual Wage (from Worksheet # 1)

     

3.

Multiply line 2 by 100  (line 2 X 100).  Enter percentage.

     

4.

If percentage from line 3 is less than or equal to 50%  (line 3 < 50%), enter $15,000.

 

If percentage from line 3 is greater than 50 %, but less than or equal to 75%  (50% < line 3 < 75%), enter $10,000.

 

This is the award amount for claimed year of wage-loss.