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Quarterly Statement Of Supplemental Benefits Paid For Self Insured Employers F207-011-000 - Washington

Quarterly Statement Of Supplemental Benefits Paid For Self Insured Employers Form. This is a Washington form and can be used in Self Insurance Workers Comp .
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Department of Labor and Industries Self-Insurance Section PO Box 44891 Olympia WA 98504-4891 360-902-6861 CertificationSvcs@Lni.wa.gov Name of Self-Insured Employer Firm Representative (if applicable) Mailing Address City State Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers UBI Number For Quarter From ZIP+4 Account ID To Self-Insured employers are entitled to reimbursement for all increased and retroactive payments of temporary total disability compensation made to injured workers entitled to such monies, in accordance with RCW 51.32.073, except those cases where an employer continued an injured worker on wages. Reimbursement shall be made upon the completion and submission of this statement. For LEP claims, the worker must be paid at the higher of method A or B. If method B is used, no supplemental reimbursement is payable. (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) Number of Days Paid (8) Amount of Reimbursement Due Employer By Amount Warrant # Department Use Only Approved for Payment Date Total (9) I (We) the undersigned, hereby certify the above stated payments have been made to the claimants identified on this report and the figures are true and complete for the period covered. Signature Date Type or print your name Title Area Code and Phone Number F207-011-111 Quarterly Statement of Supplemental Benefits 07-2015 American LegalNet, Inc. www.FormsWorkFlow.com Department of Labor and Industries Self-Insurance Certification Services PO Box 44891 Olympia WA 98504-4891 360-902-6861 CertificationSvcs@Lni.wa.gov · · · · · Quarterly Statement of Supplemental Benefits Instructions Mail completed form to the address above. A copy will be returned to you along with the reimbursement. Enter the self-insured firm name and address and/or service organization, if applicable. Reimbursements will only be issued in the name of the self-insured firm. The warrant will be mailed to c/o your service organization. A form should be submitted for each calendar quarter and year. Maximum Monthly Compensation Maximum Daily Rate Increase Multiple For Injuries Occurring During Maximum Monthly Compensation Maximum Daily Rate Increase Multiple For Injuries Occurring During 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 7/1/91 to 6/30/92 7/1/92 to 6/30/93 7/1/93 to 6/30/94 $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 1,866.75 1,973.50 2216.47 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 62.22 65.78 73.88 6.91622 6.59983 6.38394 5.99002 5.57036 5.08148 4.73875 4.41634 4.14258 3.78262 3.46627 3.18449 3.05789 3.02040 2.96679 2.87044 2.76658 2.70702 2.61110 2.51175 2.39607 2.26645 2.11895 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 7/1/11 to 6/30/12 7/1/12 to 6/30/13 7/1/13 to 6/30/14 7/1/14 to 6/30/15 7/1/15 to 6/30/15 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 4816.20 4989.40 5159.50 5263.50 5482.90 77.94 83.24 90.56 95.31 101.60 109.54 118.70 122.96 124.10 126.47 129.31 130.13 134.62 141.94 149.07 154.18 157.17 160.54 166.31 171.98 175.45 182.76 2.10412 2.05982 1.97577 1.87716 1.76105 1.63338 1.50735 1.45509 1.44182 1.41480 1.38365 1.37500 1.32916 1.26053 1.20030 1.16048 1.13841 1.09889 1.06268 1.04168 1.00000 0.00000 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 6.29374 (increase multiple) = 3,052.84/month or 101.77/day. See Example A on page 2. 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 2012, his rate at DOI would be $1.68(10.58 ÷ 6.29374). The difference between those ($8.84) times the number of days paid is the amount reimbursable to the employer. See Example B on page 2. F207-011-111 Quarterly Statement of Supplemental Benefits 07-2015 American LegalNet, Inc. www.FormsWorkFlow.com 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 $30.53 (101.77 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 ($30.53 - $4.85 = $25.68) times the number of days paid is the amount reimbursable to the employer. See Example C
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