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Itemized Statement Of Compensation DWC-50 - Rhode Island
| Itemized Statement Of Compensation Form. This is a Rhode Island form and can be used in Claim Department Of Labor And Training Workers Comp . |
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ITEMIZED STATEMENT OF COMPENSATION (DWC-50) General Instructions: Completed by: Claim Administrator. Time Frame: Within 60 days after the dontinuaniscce or suspension of compensation payments. Distribution: Original to Department of Labor and Training (D. CoLT) py to the employee and his or her attorney and also to the employer, if filed by the insurer. 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. 2. Claim Information: Employer: Name of company where the employee ws ema ployed 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 carrier, third party adnistrmi ator, 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). Date of Death: Conditional, if employee died Check appropr box as to whetheriate death was work-related or not. 3. Incident Only: Check this box if no payments were made on the claim. Complete Section 8 and return to DLT only. 4. Nonpayment of Weekly Indemnity Only: Medical Only: Check if medical payment(s) were ma on the claimde but NO weekly indemnity . Federal Jurisdiction: Check if claim fell under Federal rJuisdiction for weekly indemnity . Salary Continuation: Check if full salary was continued for employ ee. Denied: Check if claim was denied by Claim Administrator. Death: Check if death was work-related and there were no dependent s. Other: Use only if none of the above apply; for example, if the claim is unr anotherde states jurisdiction and had been sent to RI by mistake. 5. Diagnosis: Primary Written Diagnosis: Enter the primary written diagnosis supplied by medical provider. ICD Code: International (Statistical) Classification of Diseases (and Related Health Problems) code should be supplied by medical provider. Secondary Written Diagnosis: Enter the secondary written diagnosis, an ify, provided by medical provider. ICD Code: International (Statistical) Classification of Diseases (and Related Health Problems)ode should b ce supplied by medical provider. 6.Payment Information: For each and every item where payment was made, enter the total amount paid. In the case of Subrogation, check Yes or No as to whether or not the claim was subrogated. Date of First Indemnity Payment: Enter the date the first indemnity payment was made. 7. Return to Employment: Please complete all requested information. 8. This Report was Prepared by:PRINT ALL IN FORMATION Name: Print full name of person who filled out the form (report preparer). RI Adjuster License Number: Enter RI Adjuster License Numbeasr issued by the RI Department of Business Regulation. Note: DO NOT ENTER SSN Request another number from DBR. Company Name: Name of the company where the report preparer is employed. Address (including city, state, zip) M: ailing address of the company where the report preparer is employed. Phone/Ext/Email: Phone number and extension (if necessary) and email address of the report preparer. Signature/Date: Signature of the person who filled out the form and the date that the form was prepared. <<<<<<<<<********>>>>>>>>>>>>> 2State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORT ITEMIZED STATEMENT OF COMPENSATION Department of Labor and Training, Division of Workers Compensation DWC No. PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (401) 462-8006 Insurer File No. 1. EMPLOYEE INFORMATION: 2. CLAIM INFORMATION: SSN Employer Name Insurance Co. Address Claim Administrator City, State, Zip Injury date Incapacity date Date of death Work-related OR Not3. Incident Only--No payments made. Complete Section 8 and return to DLT only at above address. All others continue below. 4. NONPAYMENT OF WEEKLY INDEMNITY ONLY: Check correct box and complete appropriate information on remainder of form. *Payment info must Medical Only* be listed below Federal Jurisdiction Salary Continuation Denied Do NOT use Other if claim is Denied Death--Liability established; no dependents. Payment made to WCAF Other: 5. DIAGNOSIS: Primary Written Diagnosis ICD Code: Secondary Written Diagnosis ICD Code: (List total amount paid for 6. PAYMENT INFORMATION:each appropriate item in both columns)DATE OF FIRST INDEMNITY PAYMENT: Temporary Partial Hospital/Treatment Center Temporary Total Independent Medical Exams Permanent Total Pharmaceutical Weekly Death Benefits Chiropractic Burial Diagnostic Testing Specific - Disfigurement Attorney Fees Awarded by Court Specific - Loss of Use Penalties/Interest Vocational Rehabilitation WC Administrative Fund (WCAF) Physical Therapy Settlement Occupational Therapy Deny & Dismiss Psychological Services Other Payments: Physicians Subrogation Yes No 7. RETURN TO EMPLOYMENT: Did the employee return to employment? Yes No Unknown If yes, was it with the same employer OR a different employerUnknown Date Returned: Unknown 8. THIS REPORT WAS PREPARED BY: PLEASE PRINT Name RI Adjuster License Number Company Name Address City State Zip Code Telephone Extension Email Signature Date Distribution: DLT, Division of Workers Compensation; Employee and Attorney; Employer DWC-50 (01/03) For instructions visit our web site: www.dlt.ri.gov/wc
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