Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 18
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18State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
REPORT OF SPECIFIC 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) 462-8084
Insurer File No.
YOU MUST CHECK ONE OF THE FOLLOWING:
LOST TIME
NO LOST TIME
FEDERAL JURISDICTION
1. EMPLOYEE:
2. EMPLOYER:
SSN
FEIN
Name
Name
Address
Address
Address
Address
City, State, Zip
City, State, Zip
Phone
Date of Birth
Phone
Ext.
3. INSURANCE COMPANY NAMED ON WC POLICY:
4. CLAIM ADMINISTRATOR:
SAME AS BLOCK 3
FEIN
FEIN
Name
Name
Address
Address
Address
Address
City, State, Zip
City, State, Zip
Phone
Ext.
Phone
Ext.
RI License Number
RI License or Self-Insurance Number
5. CLAIM INFORMATION:
Injury date
Incapacity date (if appropriate)
Average Weekly Wage (including OT)
Weekly Specific Rate
Specific paid by:
Court Order
Date:
Number:
OR
Agreement of the Parties
Description of Injury/Specific:
Attorney Fee:
6. SPECIFIC PAYMENT INFORMATION:
Indicate Payment Type
Body Part
Percent of Loss Number of Weeks
Amount Paid
Date Paid
disfigurement
loss of use
disfigurement
loss of use
disfigurement
loss of use
Hearing Loss
Total/Partial Deafness
Number of Weeks
Amount Paid
Date Paid
Left Ear
occupational
traumatic
total
partial
Right Ear
occupational
traumatic
total
partial
Employee Signature:
Date:
Employer/Insurer Signature:
Date:
(Not required for Court Order)
For instructions visit our web site:
DWC-51 (01/03)
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Parent category: Business