• Worker earns a fixed monthly salary, regardless of the number of hours worked
• A completed SIF-5A Cover Sheet: Wage Calculations
• A completed SIF-5A1 Time Loss Calculation Worksheet
• If the worker and employer agree on the monthly wage amount, payroll records are NOT required.  Agreement is present when
• The worker and employer reported the same wage and bonus amounts on a 2002 or later version of the SIF-2; or
• A documented phone call with the worker resolves any discrepancy or lack of information on the SIF-2.
• If there is any disagreement or inconsistency regarding the monthly salary, or the worker indicates the presence of a second job, a consistent pattern of overtime, or multiple rates of pay, complete payroll records must be submitted to resolve the issue.

 

• Worker is an hourly-paid employee with a regular consistent work schedule
• A completed SIF-5A Cover Sheet: Wage Calculations
• A completed SIF-5A2 Time Loss Calculation Worksheet
• If the worker and employer agree on the hourly rate of pay and hours schedule to work, payroll records are NOT required.  Agreement is present when
• The worker and employer reported the same wage and bonus amounts on a 2002 or later version of the SIF-2; or
• A documented phone call with the worker resolves any discrepancy or lack of information on the SIF-2.
• If there is any disagreement or inconsistency, complete payroll records must be submitted to resolve the issue.  Payroll records must display
• Hours worked per day and the rates of pay
• An explanation of any varying pay rates (shift differentials, premium pay, overtime, etc.)
• Days worked per week
• All leave hours
• A key to any codes used

 

• Worker is an hourly-paid employee working a consistent number of days per week, but hours per day vary
• A completed SIF-5A Cover Sheet: Wage Calculations
• A completed SIF-5A3 Time Loss Calculation Worksheet
• All payroll records reviewed in determining average hours per day:  at minimum, use records for 12 months prior to the date of injury.  If the worker was not an employee with the employer at injury for 12 months, use the period of time from the date of hire to the date of injury.  (If that period is too brief to establish a pattern, use the hours of a like employee.)  Payroll records must display
• Hours worked per day and the rates of pay
• An explanation of any varying pay rates (shift differentials, premium pay, overtime, etc.)
• Days worked per week
• All leave hours
• A key to any codes used
 

• Worker is an hourly-paid employee with a varying schedule
• A completed SIF-5A Cover Sheet: Wage Calculations
• A completed SIF-5A4 Time Loss Calculation Worksheet
• All payroll records reviewed in determining average hours per month:  at minimum, use records for 12 months prior to the date of injury.  If the worker was not an employee with the employer at injury for 12 months, use the period of time from the date of hire to the date of injury.  (If that period is too brief to establish a pattern, use the hours of a like employee.)  Payroll records must display
• Hours worked per day and the rates of pay
• An explanation of any varying pay rates (shift differentials, premium pay, overtime, etc.)
• Days worked per week
• All leave hours
• A key to any codes used
 

• Worker’s pattern of employment is exclusively seasonal or intermittent
• A completed SIF-5A Cover Sheet: Wage Calculations
• A completed SIF-5A5 Time Loss Calculation Worksheet
• A work history, obtained from the worker, showing all employment for a minimum of three years prior to the date of injury/occupational disease, including all employer names, dates/periods of employment, and an explanation of any significant gaps in employment.
• Documentation of gross wages, including overtime, from all employment for the entire period covered by the work history.

 

If you have any questions, please call the Self Insurance Section at 360-902-6901 to speak with the adjudicator assigned to the claim.