Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 11
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18State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
REPORT OF INDEMNITY PAYMENT
DWC No.
Department of Labor and Training, Division of Workers' Compensation
PO Box 20190, Cranston, RI 02920-0942
Phone (401) 462-8100 TDD (401) 462-8006
Insurer File No.
YOU MUST CHECK ONE OF THE FOLLOWING:
YOU MUST CHECK ONE OF THE FOLLOWING:
INTERIM
TERMINATION OF BENEFITS UNDER NON-PREJUDICIAL AGREEMENT*
FINAL:
PAYMENT UNDER MEMO OF AGREEMENT, ORDER OR DECREE
Date of last weekly indemnity payment:
1. EMPLOYEE INFORMATION:
2. CLAIM INFORMATION:
SSN
Employer
Name
Insurance Co.
Address
Claim Administrator
City, State, Zip
Injury date
Phone
Date of Birth
Incapacity date
Single
Maximum no. of exemptions ________
Married
Date of death
NOT work-related
3. RATE INFORMATION:
AWW including Overtime
AWW (include bonus/no OT)
Spendable Base Wage
Total Cost of Living Adjustment(s)
Base Compensation Rate
Weekly Dependency Rate
4. WEEKLY COMPENSATION:
Indicate
Payment period
Payment period
Number of
Total
Variable Partial
Compensation
Settlement
Payment Type
Date from
Date through
Weeks & Days
Weekly Rate
Total Spendable
Paid
Deny&Dismiss
Amount:
TI
PI
DB
Decree No.
TI
PI
DB
Decree Date
TI
PI
DB
5. WEEKLY COMPENSATION for Variable Partial Payments: (Complete information above also)
Spendable
Spendable
Week Ending
Gross Earnings
Amount Paid
Week Ending
Gross Earnings
Amount Paid
Earnings
Earnings
Signature:
Date:
Print Name:
RI Adjuster License Number:
Phone & Extension:
*THE FOLLOWING NOTICE IS FOR EMPLOYEES TERMINATED UNDER A NON-PREJUDICIAL AGREEMENT ONLY
Weekly compensation payments have stopped. The insurer/employer has not accepted liability for this claim. If you wish to protect any rights you may
have under the Workers' Compensation Act, including possible entitlement to continued or future weekly compensation payments or payment of medical
expenses, a petition must be filed with the Workers' Compensation Court within two (2) years from the first date of incapacity.
For instructions visit our web site:
DWC-22 (01/03)
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