Free D-5.PDF - Nevada

WAGE CALCULATION FORM FOR CLAIMS AGENT'S USE
RE: Injured Employee: Social Security No.: Employer: 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 employee's 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 employee's projected working schedule, divide by 7 and multiply by 30.44. If other circumstances apply, see NAC 616C.435. Date of Injury: Claim No.: Insurer:

AVERAGE MONTHLY WAGE - Calculate AMW in the following manner: Period of earnings: beginning date Gross earnings in wage history HOURLY RATE - Hourly rate of pay projected to work per week VALUE OF ROOM AND/OR BOARD Room (Monthly Value) Board (Monthly Value) ....................................... $ ....................................... $ + tips through end date ÷ by number of days

x 30.44 . . . . . . . . . . . . . . . . . . . = Average Monthly Wage:$ x number of hours ÷ 7 x 30.44 . . . . . . . = Average Monthly Wage:$

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 to work per week = x number of days hired ÷ 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 Date x 8 ÷ 12 ÷ 30.44 . . . . . . . . . . . . . . . . . .Daily Rate:$ Signature D-5 (rev. 7/99)