Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 16
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18State of Rhode Island
Department of Labor and Training, Division of Workers’ Compensation
PO Box 20190, Cranston, RI 02920-0942 (401) 462-8100 TDD (401) 462-8006
NOTICE TO EMPLOYEES
REGARDING THE EFFECT OF ENDORSEMENT OF BENEFIT CHECK
You are presently receiving or have filed a claim to receive workers’
compensation benefits. You should know and are hereby advised that by
endorsing your workers’ compensation benefit check or upon deposit of
your workers’ compensation check into an account, you are declaring that
you are receiving benefits under the Workers’ Compensation Act. In other
words, your endorsement on a weekly benefit check is your statement that
you are entitled to receive workers’ compensation benefits for that week
under the Workers’ Compensation Act and have made no false claims or
statements or concealed any material fact.
Furthermore, if you can return to any work and receive earnings, which
includes wages, salary, commissions, bonuses, cash, and/or any other
compensation other than money, YOU MUST REPORT THESE
EARNINGS
TO
YOUR
EMPLOYER’S
CLAIM
ADMINISTRATOR
IMMEDIATELY. If you endorse a benefit check that is for a week in which
you had earnings AND YOU FAIL TO REPORT THESE EARNINGS, YOU
MAY BE PROSECUTED BY THE ATTORNEY GENERAL AND SENT TO
PRISON.
You are NOT ENTITLED to receive workers’ compensation benefits for any
time that you are imprisoned as a result of a criminal conviction.
DWC-32 (01/03)
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Parent category: Business