Washington > Workers Comp > Self Insurance
SIF-5A Cover Sheet Wage Calculations F207-156-000 - Washington
| SIF-5A Cover Sheet Wage Calculations Form. This is a Washington form and can be used in Self Insurance Workers Comp . |
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Department of Labor & Industries Self Insurance Section PO Box 44892 Olympia, WA 98504-4892 SIF-5A COVER SHEET: WAGE CALCULATIONS Claim Number Claimant Complete the appropriate form(s): Worker earns a fixed monthly salary, regardless of the number of hours worked. Complete form SIF-5A1 Worker is an hourly-paid employee with a regular consistent work schedule. Complete form SIF-5A2 Worker is an hourly-paid employee working a consistent number of days per week, but hours per day vary. Complete form SIF-5A3 Worker is an hourly-paid employee with a varying schedule. Complete form SIF-5A4 Worker's pattern of employment is exclusively seasonal or intermittent. Complete form SIF-5A5 In addition, complete each of the following sections: Bonuses: Did the worker receive any bonuses in the year prior to injury?..........................................YES If yes, complete the following calculation: $ _________________________ (total of all bonuses paid) 12 = NO $ ________________________ (avg. monthly value of bonuses) Health care benefits: Did the employer contribute towards health care benefits at the time of injury?... YES NO If yes, supply the following information: Monthly contribution to medical benefits: $ __________________ Date this contribution will end: ___________________ Monthly contribution to dental benefits: $ __________________ Date this contribution will end: ___________________ Monthly contribution to vision benefits: $ __________________ Date this contribution will end: ___________________ Different pay rates: Does the worker work a substantial number of hours at different rates of pay excluding overtime (i.e. shift differentials, premium pay, etc.)?.......................................................................................YES NO If yes, include all pay rates in the calculation of the worker's gross monthly wage. Treat each rate of pay as if it were a separate job. Complete a separate wage calculation worksheet for each rate of pay, then add those monthly wages together to arrive at the total gross monthly wage. Show final wage calculation here: $ _______________ + $ _______________ + $ _______________ + $ _______________ = $ ________________ (monthly wage, pay rate #1) (monthly wage, pay rate #2) (monthly wage, pay rate #3) (monthly wage, pay rate #4) (total gross monthly wage) Multiple jobs: At the time of injury, did the worker have more than one paying job?........................YES NO If yes, the wages from each job must be included in the calculation of the worker's gross monthly wage. Complete a separate wage calculation worksheet for each job, then add those monthly wages together to arrive at the total gross monthly wage. Show final wage calculation here: $ __________________ (monthly wage, job #1) + $ __________________ (monthly wage, job #2) + $ __________________ (monthly wage, job #3) = $ __________________ (total gross monthly wage) Other compensation: Did the worker receive tips/gratuities, board, housing, fuel, clothing allowance, or similar compensation?......................................................................................................................YES NO If yes, supply the monthly value of each type of compensation: Date this compensation will end Tips / gratuities $ _____________________ Clothing $ _____________________ Fuel $ _____________________ Board $ _____________________ Housing $ _____________________ Other (explain) $ _____________________ ______________________ ______________________ ______________________ I have thoroughly investigated this worker's wages, and am reporting complete and accurate information on these forms. Phone Number: Date: F207-156-000 SIF-5A cover sheet dp 07-2009 American LegalNet, Inc. www.FormsWorkFlow.com Employer: Authorized Rep. Signature: GENERAL INSTRUCTIONS SELECTING A PATTERN OF EMPLOYMENT If the second, third, or fourth box is selected, be sure to address the possibility of a pattern of overtime hours. If a worker has a standard schedule, but also has a consistent pattern of overtime, the overtime hours must be considered when determining which method to apply. Examples: A worker's "regular" schedule is 8 hours per day, 5 days per week, but in reality he or she also works overtime nearly every Saturday. If the hours per day remain constant, use form SIF-5A2, but base the wage calculation on 6 days per week. A worker is regularly scheduled to work 8 hours per day, 5 days per week, but also has a pattern of putting in overtime during the work week. Use form SIF-5A3 and average the hours worked per day, including the overtime hours. REPORTING THE VALUE OF HEALTH CARE BENEFITS Every employer who is contributing to medical, dental, and/or vision benefits on the date of injury MUST report the monthly value of these contributions. If the employer ends their contributions toward these benefits at different times, the monthly value of the contribution to each type of benefit must be identified, along with each end date. If all health care benefit contributions will end on the same date, and the value of the employer's contribution to each specific type cannot be identified, the total monthly value of the employer's contribution may be entered on the "Monthly contribution to medical benefits" line. IF REPORTING FIRST TIME LOSS, BUT NOT REQUESTING A WAGE ORDER: Complete the SIF-5, SIF-5A Cover Sheet, and the applicable calculation worksheet(s). Do NOT check the "wage order requested" box on the SIF-5. Supporting payroll documentation will not routinely be required when a wage order is not requested. PLEASE NOTE THAT THE DEPARTMENT WILL INVESTIGATE DISCREPANCIES IN WAGE REPORTING, EVEN IF A WAGE ORDER IS NOT REQUESTED. PAYROLL RECORDS MUST BE PROVIDED WHEN REQUESTED BY THE DEPARTMENT. IF REQUESTING A WAGE ORDER: Complete the SIF-5, SIF-5A Cover Sheet, and the applicable calculation worksheet(s). Check the "wage order requested" box on the SIF-5. ALL documentation that was reviewed in determining the wage must be submitted with the request for the wage order. IF CALCULATING WAGES BASED ON "LIKE EMPLOYEES": WARNING: This method of calculating wages should be exceptionally rare! Provide an explanation justifying why this method is necessary. Always review more than one "like employee" to ensure a fair representation (recommend 3 to 6 individuals). Complete an SIF-5A Cover Sheet and the applicable calculation worksheet(s) for each "like employee". Write the words "like employee" across the
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