Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 6

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State of Rhode Island

PLEASE CHECK IF CORRECTION OF PRIOR REPORT

PART-TIME WAGE STATEMENT

(Hired for less than 20 hours per week)

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.

EMPLOYEE INFORMATION:

CLAIM INFORMATION:

SSN

Employer

Name

Insurance Co.

Hired for________ hours each week (

Claim Administrator

Approximate)

Are these supplemental wages?

Yes

Injury date

If yes, name of supplemental employer

Incapacity date

Maximum no. of exemptions_______

Hire date

Single

Married

EMPLOYED LESS THAN 2 WEEKS:

If Yes:

OR:

1. List agreed upon hourly wage

2. Number of hrs. per week for part-time employees

Give average weekly for same or similar employment:

3. Multiply #1 by #2 for average weekly wage

EMPLOYED MORE THAN 2 WEEKS:

On the left side of the form, list gross wages prior to employee's first full day out of work. DO NOT include their week of hire or week of injury unless a full

week was paid. DO NOT SKIP WEEKS. Please calculate any overtime and/or bonus paid SEPARATELY on the right side of the form below.

LIST 26 CONSECUTIVE WEEKS:

BONUS AND OVERTIME CALCULATION:

No. of standard

Gross Wages

Block 1

Week Number

Week Ending Date

Number of weeks employed (up to 52)

hrs. worked

(No Overtime)

Block 2