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...Department of labor and industries total monthly wage calculations selfinsurance section po box sifa form olympia wa calculation cover sheet use applicable following subsections to autofill parts this summary injured worker name claim number date injury employer s completed prepared by preparer phone ext bonuses if the received any go rcw value worksheet complete health care benefits contribution medical haswill end dental contributed at time vision other compensation enter tipsgratuities driver mileage for type housingboard equipmentclothing may fuel pickupdelivery have in commission piecework addition hourly wages or transportation explain below description additional jobs employers regular continuous employment only did more than one paying job yes no appropriate each include from all is basis payment it not benefit amount sub f timeloss rate maritaldomestic single divorced widowed married separated domestic partnership dependent status eligible dependents on x excluding based tl da...