Vwc Form No. 7a - Wage Chart - Employer'S Statement Of Wage Earnings

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Wage Chart
The boxes
Reserved
VWC File Number
to the right
Employer’s Statement of Wage Earnings
are for the
use of the
Insurer Code
Insurer Location
FHM Insurance, PO Box 616648, Orlando, FL 32861
10699
insurer.
Virginia Workers’ Compensation Commission
1000 DMV Drive Richmond VA 23220
Insurer Claim Number
Employee
Address
Name of Employee
Date of Accident
Date of Hire
Employer
Address
Name of Employer
Employee’s Social Security Number
PLEASE REFER TO THE FILING INSTRUCTIONS PRINTED ON THE BACK OF THIS FORM
Week
Week
Days
Gross amount
Week
Week Ending
Days
Gross amount
Week
Week Ending
Days
Gross amount
No.
Ending
Worked
paid, including
No.
Date
Worked
paid, including
No.
Date
Worked
paid, including
Date
overtime
overtime
overtime
1
19
37
2
20
38
3
21
39
4
22
40
5
23
41
6
24
42
7
25
43
8
26
44
9
27
45
10
28
46
11
29
47
12
30
48
13
31
49
14
32
50
15
33
51
16
34
52
17
35
Totals
18
36
Value of perquisites for entire year:
Total gross earning $ ____________
Total weeks worked _______
Bonuses $
Electricity $ _______
Total value of perquisites $_____________
Meals/Lodging $
Water $
VWC use only:
Meals Only $
Telephone $ _______
Temporary Lodging $
Uniforms $ _______
Total earnings & perquisites $ _____________
House Rent $
Laundry $
AWW: ________
T
ip Income $ ________
CR: ________
INSURER OR EMPLOYER (include name & signature)
Date
Telephone number
Wage Chart
VWC Form No. 7A (rev. 07-01-06)

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