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Employees Objection To Wage Transcript DWC-31 - Rhode Island
| Employees Objection To Wage Transcript 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 OBJECTION TO WAGE TRANSCRIPT (DWC-31) General Instructions: Completed by: Employee. Time Frame: Employee must file this notice with DLT within two weeks of receipt ofWa ge Transcript. Distribution: Original to Department of Labor and Training. DLT will notify Workers Compensation Court. 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. Name: Employees full name. Address (including city, state, zip) E: mployees current mailing address. Phone: Employees current home telephone number. 2. Claim Information: Employer: Employers actual name where the employe was ee mployed at the time of the injury. Insurance Co.: Name of the workers compensation insurer OR Self-Insu ifred the company has been certified as self-insured by D LT. Claim Administrator: Name of the WC insurance carrr,ie third party administrator, or self-insured employer responsible for administering the claim. Injury Date: Date that the accident happened. Incapacity Date: First full day that the employee lost from work (include weekends and holidays). Employee Signature/Date: Signature of the employee and the date prepared. <<<<<<<<<********>>>>>>>>>>>>> 2State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORTEMPLOYEES OBJECTION TO WAGE TRANSCRIP T Department of Labor and Training, Division of Workers Compensation DWC No.PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (40 1) 462-8006 Insurer File No. 1. EMPLOYEE INFORMATION: 2. CLAIM INFORMATION: SSN Employer Name Insurance Co. Address Claim Administrator City, State, Zip Injury date Phone Incapacity date The employee objects to the discontinuance or reduction of workers compensation benefits pursuant to RIGL Section 28-35-47 and requests a review by the Workers Compensation Court, pursuant to RIGL Section 28-35-51. Employee: Date: DWC-31 (01/03) For instructions visit our web site: www.dlt.ri.gov/wc
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