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.