Fill and Sign the Report of Earnings of Injured Employee Based on Four Completed Quarters Form

South Carolina Workers’ Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737- 5723 WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: Address: City: State: Zip: Home Phone: Work Phone: Preparer's Name: Employer's Name: Address: City: State: Zip: Insurance Carrier: Preparer’s Phone #: Date of Injury: month day year A. Total Wages Paid 1. Check Applicable Method: Report of earnings of injured employee based on four completed quarters. Report of earnings of injured employee who did not complete four quarters based on actu al time worked. Report of earnings of similar employee. Injured employee did not work sufficient time before alleged injury. Hire date: _____________ Re port of earnings of injured employee based on alternative method because Form 20 results in a co mpensation rate that is not fair and just (attach documentation to show how average weekly wage and compensation ra te were calculated). 2. List total wages paid as reported to the Employment Security Commission on the Employer Quarterly Contribution and Age Reports during the four quarters immediately preceding the quarter in which the injury occurred. Do not inclu de the quarter during which the injury occurred. Quarter Ending Date Total Wages Paid 1st $ 2nd $ 3rd $ 4th $ Total Paid 2. $ 3.List total value of other allowances of any character made in lieu of wages durin g four quarters above. 3. $ 4.Add lines 2 and 3. TOTAL WAGES PAID: 4. $ 5.List total number of weeks paid to employee during the four quarters immediately precedi ng the quarter in which the injury occurred. 5. B. Average Weekly Wage 6. To calculate average weekly wage, divide total wages (line 4) by total weeks paid ( line 5). AVERAGE WEEKLY WAGE: 6. $ C. Compensation Rate 7.The general rule for calculating the compensation rate is to multiply average weekl y wage (line 6) by .6667. Estimate compensation rate by multiplying average weekly wage (line 6) by .66 67. See part 8 below to determine the actual compensation rate. 7. $ 8. The compensation rate is as follows (choose one): When average weekly wage (line 6) is less than $75.00, the compensation ra te is the average weekly wage. Enter average weekly wage on line 8. When the estimated compensation rate (line 7) is less than $75.00 and ave rage weekly wage (line 6) is more than $75.00, the compensation rate is $75.00. Enter $75.00 on lin e 8. When the estimated compensation rate (line 7) is more than the maximum compen sation rate for the year in which the injury occurred, enter the maximum compensation rate for t he year in which the injury occurred on line 8. Employee is within the exceptions listed in S.C. Code Ann. Section 42-7 -65. List applicable exception here and enter appropriate compensation rate on line 8. __________________________________________ The calculated compensation rate (line 7) applies. Enter amount from line 7 on l ine 8. WEEKLY COMPENSATION RATE: 8. $ Employer’s representative shall prepare a Form 20 and serve per R.67-211 a co py on the claimant within thirty days of beginning temporary co mpensation. See R.67-1603 when no temporary compensation is paid. NOTE: Average weekly wage represents average gross pay before taxes and other deductions. WHEN THE CLAIMANT DOES NOT AGREE WITH THE COMPENSATION RATE ON LINE 8, HE OR SHE SHOULD CONTACT THE EMPLOYER’S REPRESENTATIVE TO TRY TO REACH AN AGREEMENT AS TO THE COMPENSATION RATE. IF NO AGR EEMENT CAN BE REACHED, THE CLAIMANT SHOULD CONTACT THE CLAIMS DEPARTMENT AT (803)737- 5723. WCC Form # 20 R ev. Date 01/2014 20 STATEMENT OF EARNINGS OF INJURED EMPLOYEE