Department of Labor and Industries SelfInsurance Section PO Box 44892 Olympia, WA 985044892 Total Monthly Wage Calculations SIF5A Form Wage calculation cover sheet: Use applicable following subsections to autofill parts of this summary form. Injured Work Name: Date of Injury: Date Form(s) Completed: Prepared By: Wage Order Are you requesting a wage order at this time? Claim Number: Employer Name: Preparer Phone: Ext. Yes No Bonuses If the injured worker received any bonuses, go to the Bonuses RCW 51.08.178(3) Monthly Value of Bonuses: worksheet to complete this section. Health Care Benefits Complete this section if the employer contributed at the time of injury. Other Compensation Enter the monthly value for any type of compensation the injured worker may have received in addition to hourly wages or health care benefits. Monthly contribution to medical benefits: Monthly contribution to dental benefits: Monthly contribution to vision benefits: Monthly contribution to health care benefits: Tips/Gratuities: Housing/Board: Fuel: Commission: Transportation: Description of "other" wages: $0.00 Date contribution has/will end: Date contribution has/will end: Date contribution has/will end: $0.00 Driver Mileage: Equipment/Clothing: Driver pickup/delivery: Piecework: Other (explain below): Total monthly value of other compensation: $0.00 Additional Jobs (Other Employers) for Regular and Continuous Employment RCW 51.08.178(1) only Did the injured worker have more than one paying job at the time of injury? Yes If yes, complete the appropriate worksheet(s) for each job. $0.00 + + = Include wages from all other employers at the Monthly wage, Monthly wage, Monthly wage, time of injury. additional Monthly wage for additional additional Employer #3: all additional jobs Employer #2: Employer #1: (Enter Name) (Enter Name) (Enter Name) Total Monthly Wage (this is the basis for workers compensation payment; it is not the benefit amount) $0.00 Monthly Wage for job of injury + $0.00 Monthly Value of Bonuses + $0.00 Monthly Value of Other Compensation + $0.00 Monthly Wage for All Additional Jobs = $0.00 Sub Total of Monthly Wage + $0.00 Monthly Value of Health Care Benefits = No $0.00 TOTAL MONTHLY WAGE F207156000 062016 American LegalNet, Inc. www.FormsWorkFlow.com Department of Labor and Industries SelfInsurance Section PO Box 44892 Olympia, WA 985044892 Injured Worker Name:0 Total Monthly Wage Calculation SIF5A Form 0 Date of Injury: Claim Number: 1/0/1900 TimeLoss Compensation Rate Calculation Date of Injury: 1/0/1900 Single, Divorced or Widowed Married, Separated or Domestic Partnership Number of eligible dependents at date of injury: Marital/Domestic Partnership and Dependent status at date of injury: TimeLoss Compensation Rate, Excluding Health Care Benefits $0.00 Sub Total of Monthly Wage x % based on marital / dependents status = $0.00 *Monthly TL Compensation Rate ÷ 30 Days per month = $0.00 *Daily TL Compensation Rate This rate will apply *The monthly/daily rate must never exceed the maximum or fall below the minimum rates allowed by law (RCW while the 51.32.090). employer(s) continues to Does rate above exceed the maximum? contribute to Yes No health care Does the rate above fall below the minimum? benefits. Yes No If yes, what is the maximum (or minimum) daily rate this injured worker can receive? TimeLoss Compensation Rate, Including Health Care Benefits x = ÷ = $0.00 Total Monthly Wage 0% % based on marital / dependents status $0.00 *Monthly TL Compensation Rate 30 Days per month $0.00 *Daily TL Compensation Rate This rate will apply *The monthly/daily rate must never exceed the maximum or fall below the minimum rates allowed by law (RCW when the 51.32.090). employer(s) stops contributing to Does the rate above exceed the maximum? the health care Yes No benefits. Does the rate above fall below the minimum? Yes No If yes, what is the maximum (or minimum) daily rate this injured worker can receive? The rates above are based on earnings on the date of injury/manifestation and may increase or decrease. Examples could include: · Dependent Status · Cost of Living Adjustments · Health Care Benefit Changes F207156000 062016 American LegalNet, Inc. www.FormsWorkFlow.com Department of Labor and Industries SelfInsurance Section PO Box 44892 Olympia, WA 985044892 Injured Worker Name:0 Regular and Continuous Employment RCW 51.08.178(1) 0 Date of Injury: 1/0/1900 To Get Started: Determine the appropriate employment pattern for the injured worker and then complete one of the following worksheets: Regular and Continuous Employment RCW 51.08.178(1) Default Category Seasonal or Intermittent Employment RCW 51.08.178(2) "Like" or Similar Employment RCW 51.08.178(4) Claim Number: If the inured worker's pattern is Regular and Continuous Employment choose the method that most closely represents the employment pattern for the injured worker and attach the corresponding payroll documentation. Salaried Employee Use this method when the injured worker earns a fixed monthly salary. Monthly Salary = Monthly Wage Overtime hours should be calculated separately using averaging of hours. Regularly Scheduled Hourly Employee Including Minor Variations Use this method when: The injured worker had only one rate of pay and; Worked a regular schedule (can include a minor variation) Hourly Rate Number of days worked per week: x Hours per day x *Days per month = $0.00 Monthly Wage *Days per month are defined by law and are based on the number of days worked per week. To determine if the regular schedule had a minor variation, completed the "Calculation of Days worked per week Days per month Minor Variation for Regularly 1 5 Scheduled Employee One Rate 2 9 of Pay" section. When the 3 13 employee is paid at only one 4 18 rate of pay. 5 22 6 26 7 30 If the injured worker worked a varying number of days per week, or received multiple rates of pay. Go to the "Representative Period Used for Averaging Hours" section. "Regularly scheduled" means the injured worker works the same schedule on each day of the week, all the time, or works the same number of hours per day and days per week in a regular pattern. Overtime hours should be calculated separately using averaging of hours. F207156000 062016 American LegalNet, Inc. www.FormsWorkFlow.com Department of Labor and Industries SelfInsurance Section PO Box 44892 Olympia, WA 985044892 Injured Worker Name:0 Regular and Continuous Employment RCW 51.08.178(1) 0 Date of Injury: Claim Numbe