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FEDERAL (ERICA) PROCEDURE MANUAL Chapter 21400 Part 2 Claims Ageless Determinations TABLE OF CONTENTS Paragraph and Subject Page Date Trans. No. 1 2 3 4 5 6 7 8 Table of Contents. . . . . . . Purpose
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How to fill out Part E wage-loss worksheet:

01
Start by gathering all necessary information, such as your name, contact details, and employment details.
02
Next, provide the dates of your injury or illness and indicate whether you have returned to work or are still on leave.
03
In the worksheet, you will find a section to list your average weekly wage before the injury. Include any overtime or bonuses if applicable.
04
If you have returned to work, indicate your current average weekly wage in the designated section.
05
Calculate the difference between your pre-injury average weekly wage and your current average weekly wage. This will show your wage loss.
06
In case you are still unable to work, leave the current average weekly wage section blank and calculate your wage loss based on your pre-injury average weekly wage.
07
If you are receiving any wage replacement benefits, such as workers' compensation or disability payments, include these in the worksheet as well.
08
Finally, review the completed worksheet for accuracy and make any necessary corrections before submitting it.

Who needs Part E wage-loss worksheet:

01
Individuals who have experienced a work-related injury or illness and want to calculate their wage loss.
02
Employees who are still on leave due to the injury or illness as well as those who have returned to work.
03
Anyone who is receiving wage replacement benefits and needs to account for their current average weekly wage in relation to their pre-injury wage.
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Part E wage-loss worksheet is a form used to calculate the amount of wages lost due to a specific event or situation.
Individuals who have experienced a loss of wages and need to report it for tax or other purposes are required to file part E wage-loss worksheet.
Part E wage-loss worksheet must be filled out by providing information about the event or situation that caused the loss of wages, as well as the amount of wages lost.
The purpose of part E wage-loss worksheet is to document and calculate the amount of wages lost, which can be used for tax deductions or insurance claims.
Information such as the dates of the event causing the wage loss, the amount of wages lost, and any supporting documentation must be reported on part E wage-loss worksheet.
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