Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 8
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18Employee’s Certificate of Dependency Status
Check if this is a corrected report
State of Rhode Island
Department of Labor and Training
DWC claim number
Division of Workers’ Compensation
P. O. Box 20190
Claim Administrator
File Number
Cranston, RI 02920-0942
Phone (401) 462-8100
1. Employee information:
2. Claim Information:
: XXX-XX-
SSN
Male
Female
Employer Name
Name
Claim Administrator
Address
Address
City, ST Zip
City, ST Zip
Date of
Phone
Injury Date
Incapacity Date
Birth
Employee: complete this form and return it to the Claim Administrator. This information is
needed to calculate your compensation rate.
3. Marital Status
At the time of the injury the employee was
Single
Married
Spouse works
Spouse does not work
Spouse’s name
Enter the maximum number of Federal Exemptions you are allowed to claim
4. Number of Federal
for Federal income tax. Include yourself, your spouse, your dependents, and
Exemptions
any other exemptions.
A dependent for workers’ compensation includes children you support who are:
•
Under age 18, or age 18 to 23 and a full time student
5. Dependents
•
Mentally or physically incapacitated from earning at any age
Dependent’s Name
Date of Birth
Relationship
Full time student?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Employee’s Signature
Date
DWC-04(7/12)
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Parent category: Business