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STATE OF WASHINGTON

DEPARTMENT OF LABOR AND INDUSTRIES


PO BOX 44291, OLYMPIA, WASHI NGTON 98504-4291
SANDRA DASILVA
14246 124TH AVE NE APT A102
KIRKLAND WA 98034-1466
Dear Ms. Dasilva:
August 12, 2014
CLAIM NUMBER AV89859
INJURY DATE 06/10/2014
DATE OF BIRTH 11/11/1980
CLAIMANT DASILVA
SANDRA A
I have reviewed the information in your file and have issued an order
that sets your wages. These wages are used in determining the rate of
your time-loss compensation benefits.
If
11
NONE per month" is listed in the additional wages section, this
means:
The wage or benefit is not part of your monthly earnings or,
On the date of injury or disease manifestation, the employer
was not contributing to or providing the benefit.
Please review the information on the order carefully to ensure there
are no errors.
If you disagree with any information in the order setting your wages,
you must submit a written protest within 60 days of the date you
received the order or it will become final.
If your employer provided you with housing, board, or fuel, or
contributed to health care coverage, and the benefit changes or ends,
please send written notification to the department immediately. Your
time-loss compensation rate can be adjusted for up to 60 days prior to
the date we received your written notification.
If you have any questions, please contact me at the phone number
below.
Sincerely,
Deondra Cooley
Claim Manager, Unit K
PHONE: (360) 902-4288
FAX: (360) 902-4567
ORIG: WORKER - SANDRA DASILVA
CC: EMPLOYER - SUITE RESTAURANT/LOUNGE
Page 1 of 1 WORKER COPY (UK2P: WL: UK)
STATE OF WASHINGTON
DEPARTMENT OF LABOR AND INDUSTRIES
DIVISION OF INDUSTRIAL INSURANCE
PO BOX 44291
OLYMPIA, WA 98504-4291
SANDRA DASILVA
14246 124TH AVE NE APT A102
KIRKLAND WA 98034-1466
MAILING DATE
CLA!lvl NUMBER
INJURY DATE
CLAIMANT
EMPLOYER
UBI NUMBER
ACCOUNT ID
RISK CLASS
SERVICE LOC
08/12/2014
AV89859
06/10/2014
DASILVA
SANDRA A
SUITE RESTAURAN
603 023 697
562, 275-01
3905
Seattl e
NOTICE OF DECISION
The worker's wage is set by taking into account the following:
The wage for the job of injury is based on $12.00 per hour,
8.00 hours per day, 5.00 days per week= $2,112.00 per month.
Additional wage for the job of injury include:
Health Care Benefits
Tips
Bonuses
Overtime
Housing/Board/Fuel
NONE per month
$65.27 per month
NONE per month
$211 . 20 per month
NONE per month
Worker's total gross wage received from all employment at the time of
injury is $2,388.47 per month.
Worker's marital status eligibility on the date of this order is
single with 2 children.
Supervisor of Industrial I nsurance
By Deondra Cooley
Claim Manager
(360) 902- 4288
ATTACHMENT
THIS ORDER BECOMES FINAL 60 DAYS FROM THE DATE IT IS
COMMUNICATED TO YOU UNLESS YOU DO ONE OF THE FOLLOWING: FILE
A WRITTEN REQUEST FOR RECONSIDERATION WITH THE DEPARTMENT OR
FILE A WRITTEN APPEAL WITH THE BOARD OF INDUSTRIAL INSURANCE
APPEALS. IF YOU FILE FOR YOU SHOULD INCLUDE THE
REASONS YOU BELIEVE THI S DECISION IS WRONG AND SEND IT TO:
DEPARTMENT OF LABOR AND INDUSTRIES, PO BOX 44291, OLYMPIA, WA
98504-4291. WE WILL REVIEW YOUR REQUEST AND ISSUE A NEW ORDER.
IF YOU FILE AN APPEAL, SEND IT TO: BOARD OF INDUSTRIAL INSURANCE
APPEALS, PO BOX 42401, OLYMPIA WA 98504-2401 OR SUBMIT IT ON AN
ELECTRONIC FORM FOUND AT HTTP://WWW.BIIA.WA.GOV/.
Page 1 of 2 WORKER COPY (UK2P:WA:UK)
STATE OF WASHINGTON
DEPARTMENT OF LABOR AND INDUSTRIES
DIVISION OF INDUSTRIAL INSURANCE
PO BOX 44291
OLYMPIA
1
WA 98504-4291
MAILED TO: WORKER - SANDRA DASILVA
MAILING DATE
CLAIM NUMBER
INJURY DATE
CLAIMANT
EMPLOYER
UBI NUMBER
ACCOUNT ID
RISK CLASS
SERVICE LOC
08/12/2014
AV89859
06/10/2014
DASILVA
SANDRA A
SUITE RESTAURAN
603 023 697
562/ 275-01
3905
Seattle
14246 124TH AVE NE APT A102
1
KIRKLAND WA 98034-1466
EMPLOYER - SUITE RESTAURANT/LOUNGE
10500 NE 8TH ST STE 125
1
BELLEVUE WA 98004-8627
PROVIDER - EVERGREEN HOSPITAL MEDICAL CEN
PROF SRVC GRP, 12040 NE 128TH ST, KIRKLAND WA 98034-3013
THIS ORDER BECOMES FINAL 60 DAYS FROM THE DATE IT IS
COMMUNICATED TO YOU UNLESS YOU DO ONE OF THE FOLLOWING: FILE
A WRITTEN REQUEST FOR RECONSIDERATION WITH THE DEPARTMENT OR
FILE A WRITTEN APPEAL WITH THE BOARD OF INDUSTRIAL INSURANCE
APPEALS. IF YOU FILE FOR RECONSIDERATION, YOU SHOULD INCLUDE THE
REASONS YOU BELIEVE THIS DECISION IS WRONG AND SEND IT TO:
DEPARTMENT OF LABOR AND INDUSTRIES, PO BOX 44291, OLYMPIA, WA
98504-4291. WE WILL REVIEW YOUR REQUEST AND ISSUE A NEW ORDER.
IF YOU FILE AN APPEAL, SEND IT TO: BOARD OF INDUSTRIAL INSURANCE
APPEALS, PO BOX 42401, OLYMPIA WA 98504-2401 OR SUBMIT IT ON AN
ELECTRONIC FORM FOUND AT HTTP://WWW.BIIA.WA.GOV/.
Page 2 of 2 WORKER COPY (UK2P: WA: UK)