Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 14
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18State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
WAGE TRANSCRIPT
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.
This form will not be accepted for filing unless all information is completed.
1. EMPLOYEE INFORMATION:
2. CLAIM INFORMATION:
SSN
Employer
Name
Insurance Co.
Address
Claim Administrator
City, State, Zip
Injury date
Phone
Incapacity date
3. INSURER COMPLETE:
This wage transcript is submitted to support a:
Discontinuation of benefits. The employee has returned to work at a wage equal or greater than he or she
earned at the time of the injury.
Reduction of benefits. The employee has returned to work at a wage less than he or she earned at the time
of the injury.
Date benefits were discontinued or reduced:
Pre-injury average weekly wage, not including overtime:
4. EMPLOYER COMPLETE:
Post-Injury Earning Information -- WEEKS MUST BE CONSECUTIVE
Number of
Amount of
Period Start Date Period End Date
Payment Rate
Hours Worked
Earnings
Week 1
Week 2
:
Employer Name
Address:
City, State Zip:
Phone:
Employer/Insurer Signature:
Date:
For instructions visit our web site:
DWC-30 (01/03)
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