Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 4
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18State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
MEMORANDUM OF AGREEMENT
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:
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
List injured body parts and nature of injury:
Injury date:
First date of first disability:
Place where injury occurred:
5. DISABILITY TYPE: (check all that apply)
Death Benefits/Date of Death
Temporary Total as of
Payable to:
Temporary Partial as of
Permanent Total as of
Single
Married
Number of Exemptions
6. RATE INFORMATION:
AWW (include bonus/no OT)
Average Overtime Amount
AWW including Overtime
Number of Dependents
Spendable Base Wage
Weekly Dependency Rate
Base Compensation Rate
Total Weekly Rate
7. DATE OF INITIAL PAYMENT UNDER MOA:
Does employee have other employers?
Yes
No
If yes, attach a wage statement from each employer.
Is this a recurrence of a previous injury?
Yes
No
Previous disability end date:
Has the employee worked at least 26 weeks prior to this recurrence?
Yes
No
If yes, a new wage statement is required.
Signature:
Date:
Print Name:
RI Adjuster License Number:
Phone & Extension:
NOTICE TO EMPLOYEES RECEIVING WORKERS' COMPENSATION BENEFITS:
YOU MUST REPORT ANY EARNINGS you receive to the Claim Administrator that pays your benefits. Failure to report earnings may
subject you to civil or criminal liability. Your endorsement on a benefit check is your statement that you are qualified to receive
workers' compensation benefits. You are NOT entitled to receive workers' compensation benefits for any time that you are imprisoned
as a result of a criminal conviction.
ATTACH WAGE STATEMENT(S) AND DEPENDENCY FORM
For instructions visit our web site:
DWC-02 (01/03)
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Parent category: Business