Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 17
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18State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
ITEMIZED STATEMENT OF COMPENSATION
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.
1. EMPLOYEE INFORMATION:
2. CLAIM INFORMATION:
SSN
Employer
Name
Insurance Co.
Address
Claim Administrator
City, State, Zip
Injury date
Incapacity date
Date of death
Work-related OR Not
3
Incident Only
.
--No payments made. Complete Section 8 and return to DLT only at above address.
All others continue below.
4. NONPAYMENT OF WEEKLY INDEMNITY ONLY:
Check correct box and complete appropriate information on remainder of form.
*Payment info must
Federal Jurisdiction
Salary Continuation
Denied
Medical Only*
be listed below
Do NOT use Other
if claim is Denied
Death--Liability established; no dependents. Payment made to WCAF
Other:
5. DIAGNOSIS:
Primary Written Diagnosis
ICD Code:
Secondary Written Diagnosis
ICD Code:
(List total amount paid for
6. PAYMENT INFORMATION:
DATE OF FIRST INDEMNITY PAYMENT:
each appropriate item in both columns)
Hospital/Treatment Center
Temporary Partial
Temporary Total
Independent Medical Exams
Pharmaceutical
Permanent Total
Chiropractic
Weekly Death Benefits
Burial
Diagnostic Testing
Attorney Fees Awarded by Court
Specific - Disfigurement
Specific - Loss of Use
Penalties/Interest
Vocational Rehabilitation
WC Administrative Fund
(WCAF)
Physical Therapy
Settlement
Occupational Therapy
Deny & Dismiss
Psychological Services
Other Payments:
Yes
No
Physicians
Subrogation
Did the employee return to employment?
Yes
7. RETURN TO EMPLOYMENT:
No
Unknown
If yes, was it with the
same employer OR a
different employer
Unknown
Date Returned:
Unknown
8. THIS REPORT WAS PREPARED BY:
PLEASE PRINT
Name
RI Adjuster License Number
Company Name
Address
City
State
Zip Code
Telephone
Extension
Email
Signature
Date
Distribution: DLT, Division of Workers' Compensation; Employee and Attorney; Employer
For instructions visit our web site:
DWC-50 (01/03)
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Parent category: Business