Calculation: Amount of increase to bring time loss payments up to the fiscal 96-97 level required by law. Dept of Labor and Industries Self Insurance Certification Section QUARTERLY STATEMENT OF SUPPLEMENTAL BENEFITS INSTRUCTION Submit BOTH COPIES of this statement immediately following the calendar quarter reported. Mail to: Department of Labor and Industries, Self-Insurance, Certification Services, PO Box 44891, Olympia WA 98504-4891. A copy will be returned to you along with the reimbursement. Head as Indicated. Enter your self-insured firm name, address the warrant should be mailed to, c/o your service organization if applicable certificate number and the inclusive dates of the calendar quarter and the year. Reimbursements will only be made in selfinsurance certificate firm name. For Injuries Occurring During Maximum Monthly Compensation Maximum Daily Rate Increase Multiple For Injuries Occurring During Maximum Monthly Compensation Maximum Daily Rate Increase Multiple 7/1/71 to 6/30/72 7/1/72 to 6/30/73 7/1/73 to 6/30/74 7/1/74 to 6/30/75 7/1/75 to 6/30/76 7/1/76 to 6/30/77 7/1/77 to 6/30/78 7/1/78 to 6/30/79 7/1/79 to 6/30/80 7/1/80 to 6/30/81 7/1/81 to 6/30/82 7/1/82 to 6/30/83 7/1/83 to 6/30/84 7/1/84 to 6/30/85 7/1/85 to 6/30/86 7/1/86 to 6/30/87 7/1/87 to 6/30/88 7/1/88 to 6/30/89 7/1/89 to 6/30/90 7/1/90 to 6/30/91 $485.06 508.31 525.50 560.06 602.25 660.19 707.94 759.62 809.81 886.87 967.81 1,053.44 1,097.06 1,110.69 1,130.75 1,168.69 1,212.56 1,652.33 1,713.00 1,780.75 16.17 16.94 17.52 18.67 20.08 22.01 23.60 25.32 26.99 29.56 32.26 35.11 36.57 37.02 37.69 38.95 40.42 55.07 57.10 59.35 6.07528 5.79736 5.60772 5.26169 4.89306 4.46362 4.16258 3.87936 3.63889 3.32269 3.04481 2.79730 2.68608 2.65316 2.60607 2.52143 2.43020 2.37789 2.29363 2.20635 7/1/91 to 6/30/92 7/1/92 to 6/30/93 7/1/93 to 6/30/94 7/1/94 to 6/30/95 7/1/95 to 6/30/96 7/1/96 to 6/30/97 7/1/97 to 6/30/98 7/1/98 to 6/30/99 7/1/99 to 6/30/00 7/1/00 to 6/30/01 7/1/01 to 6/30/02 7/1/02 to 6/30/03 7/1/03 to 6/30/04 7/1/04 to 6/30/05 7/1/05 to 6/30/06 7/1/06 to 6/30/07 7/1/07 to 6/30/08 7/1/08 to 6/30/09 7/1/09 to 6/30/10 7/1/10 to 6/30/11 1,866.75 1,973.50 2,216.47 2,338.33 2,497.22 2,716.70 2,859.40 3,047.90 3,286.20 3,561.00 3,688.90 3,722.90 3,794.00 3,879.40 3,903.80 4,038.50 4,258.40 4,472.10 4,625.60 4,715.30 62.22 65.78 73.88 77.94 83.24 90.56 95.31 101.60 109.54 118.70 122.96 124.10 126.47 129.31 130.13 134.62 141.94 149.07 154.18 157.17 2.10474 1.99088 1.86132 1.84829 1.80938 1.73554 1.64893 1.54694 1.43479 1.32408 1.27817 1.26652 1.24278 1.21543 1.20783 1.16756 1.10728 1.05437 1.01939 1.00000 For calculating amount of full time loss payments reimbursable: Multiply the amount of time loss income entitled to an injured worker at the time of injury by the multiple for the fiscal year in which the injury occurred to determine the total amount now due to the injured worker. Example: For a worker injured in January 1972 entitled to the maximum,$485.06, i.e., 16.17 (maximum daily rate) x 6.07528 (increase multiple) = 2,946.88/month or 98.24/day. See Example A. When paying maximum compensation, reimbursement cannot exceed 90 days per quarter. For calculating the amount of Social Security Offset (SSO) payments reimbursable: Divide the amount the claimant is presently being paid by the multiple for the fiscal year in which the injury occurred to get the rate at date of injury (DOI). The difference between the amount presently being paid and the rate at DOI times the number of days paid is the amount reimbursable. Example: If a worker injured in January 1972 is receiving a SSO rate of $10.58 as of July 2010, his rate at DOI would be $1.74(10.58 ÷ 6.0758). The difference between those ($8.84) times the number of days paid is the amount reimbursable to the employer. See Example B. For calculating the amount of Loss of Earning Power (LEP) payments reimbursable: For LEP claims the worker must be paid at the higher of Method A or B. If the worker is paid under Method B, no supplemental reimbursement is payable. If paid under Method A, please submit your LEP calculation worksheet with your request for reimbursement. Please use two lines to provide the following information. List original time-loss calculations on line 1, even if full time loss has not been paid. Enter LEP rates on line 2.If a worker was injured in January 1972 and was entitled to maximum, $485.06, then returned to work in July 2008 at a lesser paying position receiving, for example, 30% LEP, he would be getting compensation of $29.47 (98.24 x 30%) a day. The Time Loss at DOI (column 4) would be$4.85 (16.17 x 30%) a day. The difference between these two amounts ($29.47 - $4.85 = $24.62) times the number of days paid is the amount reimbursable to the employer. See Example C. F207-011-111 statement of SBP instructions 07-2010 American LegalNet, Inc. www.FormsWorkFlow.com Claim Detail: 1. 2. 3. 4. 5. 6. 7. 8. 9. Enter the “S”, “T” , and "W" claim numbers assigned by the Department. List in NUMERICAL ORDER. (Reimbursement will not be made on claims reported without the assigned “S”, “T”, and "W" numbers or not in numerical order. Type or print the name of the injured worker as it appears on the claim. Enter the date of injury or the date of first knowledge of an occupational disease. Enter the daily time loss compensation entitled to the worker at the time of injury. LEP and SSO on a separate sheet. *Indicate if on Social Security Offset (SSO) or Loss of Earning Power (LEP). Enter the increased amount of daily time loss compensation entitled to the injured worker calculated by the increase multiples shown above. For claimants on SSO or LEP enter amount presently being paid. Enter the amount of increase in daily time loss compensation. (Item 5 minus Item 4) Enter the number of days the injured worker was paid compensation at the increased rate during the calendar period reported. If number of days reported exceeds the total number of days in the quarter, USE A SEPARATE SHEET TO REPORT EXCESS DAYS. IDENTIFYTHIS SHEET BY THE CALENDAR QUARTER PAID. Multiply Item (6) by Item (7) to determine the total increase paid to claimant. Total all entries in column (8) to determine the amount of reimbursement due to firm. NOTE: REIMBURSEMENT WILL ONLY BE MADE FOR THE CURRENT 3 YEARS, EXCEPT FOR CASES IN LITIGATION. Reporting Examples: (1) “S”, “T” & "W" Claim Number (2) Name of Injured Worker (3) Date of Injury (4) T/L Comp. @ D.O.I. (5) T/L Now W/Increase Added (6) Amount of Increase (7) Numbe r of Days Paid (8) Amount of Reimbursement Due Employer A. S123456 John Peters 1/1/72 16.17 98.24 82.07 90 7,386.30 B. S456789 SSO Mary Smith 1/1/72 1.74 10.58 8.84 90 795.60 C. S789123 Fred Schwartz 1/1/72 16.17 98.24 82.07 4.85 29.47 24.62 90 2,215.80 LEP 30% dates Department of Labor and Industries Self Insurance Certification Service PO Box 44891 Olympia WA 98504-4891 F207-011-111 statement of SBP instructions 07-2010 American LegalNet, Inc. www.FormsWorkFlow.com