Part E Wage Loss Worksheet - # 3
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Employee’s Name: |
File #:
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Claims Examiner’s
Name: |
District Office: |
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Determine Percentage of Wage Loss and Award Amount
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1. |
Adjusted Earnings (from Worksheet # 2, line 6). |
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2. |
Divide line 1 by the Average Annual Wage (from Worksheet #
1) |
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3. |
Multiply line 2 by 100 (line 2 X
100). Enter percentage. |
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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.* |
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* Repeat for each claimed year. Sum total of all years = Total Amount of wage loss award.