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Employees Certificate Of Dependency Status DWC-04 - Rhode Island
| Employees Certificate Of Dependency Status Form. This is a Rhode Island form and can be used in Claim Department Of Labor And Training Workers Comp . |
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EMPLOYEES CERTIFICATION OF DEPENDENCY STATUS (DWC-04) General Instructions: Completed by: Employee. Time Frame: No set time frame. However, if the eoyee doesmpl not complete and forward this form to the claim administror at promptly, it may result in a delay of payment. Distribution: Original from employee to claim administrator or employer. Claim administrator must attach to appropriate documentation when filing with DLT. Attachments: None. Definitions: PLEASE CHECK IF CORRECTION OF PRIOR REPORT: Check if sending in an amended form. 1. Employee Information: SSN: Employees Social Security Number. Male/Female: Check one. Name: Employees full name. Address (including city, state, zip) E: mployees current mailing address. Phone: Employees current home telephone num ber. Date of Birth: Date the employee was born. 2. Claim Information: Employer: Employers actual name where the employe was ee mployed at the time of the injury. Claim Administrator: Name of the WC insurance carrier, third party administrator, or self-insured employer responsible for administering the claim. Address (including city, state, zip) Mailing address of: the claim administrator. Injury Date: Date that the accident happened. Incapacity Date: First full day that the employee lost from work (include weekends and holidays). 3. Marital Status & Exemption Information: Were you married at the time of your injury?: Check correct box. If Yes, Spouse Name: First and last name of spouse. If Yes, does your spouse work?: Check correct box. Spouse SSN: Completion of the Social Security Number for the spouse is optional. Please put an appropriate number in each box: Exemption information is used by the claim administrator to calculate the weekly compensation amount. Failure to provide it may result in a delay of payment. Yourself: The employee is automatically entitled to one exemption. Spouse: Enter 1 in this box if employee is married. Total Dependents Listed Below: Add up the number of dependents in Section 4 and put the total in this box. Total Other: If employee is entitled to exemptions for over 65 and/or blind, enter number here. Total Number of Exemptions: Add above numbers to get total number of exemptions. Dependents Name: First and last name of each dependent. Dependents Date of Birth: Date each dependent was born. Dependents Social Security Number: Completion of the Social Security Number for the dependent is optional. If over 18 and under 23, Full-Time Student?: For each dependent over the age of 18 and und the age of 23, chereck box as to whether or not each one is a full-time student at an accredited educational facility. Employee Signature/Date: Signature of employee and date form was completed. <<<<<<<<<********>>>>>>>>>>>>> 2State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORT EMPLOYEES CERTIFICATE OF DEPENDENCY STATUS Department of Labor and Training, Division of Workers Compensation DWC No. Phone (401) 462-8100 TDD (401) 462-8006 Insurer File No. 1. EMPLOYEE INFORMATION: 2. CLAIM INFORMATION: SSN Male FemaleEmployer Name Claim Administrator Address Address City, State, Zip City, State, Zip Phone Date of Birth Date of Injury Date of IncapacityTHE EMPLOYEE MUST COMPLETE ALL REQUIRED INFORMATION: Please return this form to your employers workers compensation Claim A dministrator. If they do not receive this completed form promptly, it may result in a delay of your claim. 3. MARITAL STATUS & EXEMPTION INFORMATION:(Needed to calculate your weekly compensation payment) Were you married at the time of your injury? Yes No If Yes, Spouse Name: If Yes, does your spouse work? Yes No Spouse SSN **: Please put an appropriate number in each box -- you are entitled to one exemption for yourself and one for your spouse. Yourself 1 Spouse Total Dependents Listed Below (Other: You may be entitled to additional exemptions if you or your spouse ar e Total Other over 65 or blind. Please contact your employers workers compensation Claim Total Number of Exemptions Administrator for further information) (Add all of the above) 4. DEPENDENT INFORMATION List each dependent child below. A dependent child includes: ~ Children under the age of eighteen living with you or whom you wer e required to support at the time of the injury ~ Children you support who are over eighteen but who are mentally or physically incapacitated from earning ~ Children under the age of twenty-three who are full-time students at an accredited educational facility Dependents Dependents Dependents If over 18 and under 23, Name: Date of Birth: Social Security Number:** Full-Time Student? 1. Yes No 2. Yes No 3. Yes No 4. Yes No 5. Yes No 6. Yes No 7. Yes No 8. Yes No 9. Yes No10. Yes NoEmployee Signature: Date: ** Completion of the Social Security Number for Spouse and Dependents is optional. Employee Note: DO NOT return this form to the Department of Labor and Training - RETURN TO Claim AdministratorDWC-04 (01/03) For instructions visit our web site: www.dlt.ri.gov/wc
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