Form Dwc-25 - Report Of Earnings - Department Of Labor And Training Page 2
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2Report of Earnings (DWC-25 1/2003)
Page 1
The claim administrator (the company handling the claim: the insurer, self-insured employer or
third party administrator) sends the form to the employee to complete at the beginning of a
claim, at reasonable intervals throughout the claim, and at the end of a claim. The employee
completes the form and returns it to the claim administrator.
Top of form:
Insurer File Number: Provide the claim number or file identification number for the
company handling the claim: the insurer, self-insured employer or third party
administrator.
1. Employee Information. The claim administrator completes section 1.
SSN: enter at least the last 4 digits of the employee’s social security number or the
employee ID number assigned by DLT. DO NOT use a fictitious number.
Name: enter the employee’s first name, middle initial and last name.
Address: complete the employee’s street address, city, state and zip code.
Provide the employee’s phone number if available.
2. Claim Administrator Information. The claim administrator completes section 2.
Complete the information for the company handling the claim. Provide the claim
administrator business name, mailing address, and phone number.
Reporting period. From date: enter the first day the employee lost time from work due
to the injury (incapacity date).
3. Notice to Employees Receiving Workers’ Compensation: Employee should read the
complete notice.
4. Employee Complete:
Read the questions and WRITE IN either YES or NO.
If you answered NO to BOTH questions, sign and date the form. Return the completed
form to the claim administrator (not to RI Department of Labor and Training).
If you answered YES to either question, complete the employer and earnings
information.
Employer information: give the business name and address of the employer that
provided the earnings.
5. The employee reports earnings received: give the date of earnings and amount received.
Attach another page if needed.
Signature:
The employee must sign and date the form.
A witness to the employee’s signature must sign and date the form.
Return the form to the CLAIM ADMINISTRATOR, not to the Department of Labor & Training.
Revised 12/12/2016
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