Rhode Island > Workers Comp > Department Of Labor And Training > Claim
Memorandum Of Agreement DWC-02 - Rhode Island
| Memorandum Of Agreement Form. This is a Rhode Island form and can be used in Claim Department Of Labor And Training Workers Comp . |
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MEMORANDUM OF AGREEMENT (DWC-02) General Instructions: Completed by: Claim Administrator. Time Frame: No set time frame. However an MOA will be expected if paym,ents de underma a Non-Prejudicial Agreement go beyond 13 weeks. The MOA must be filed with the Department of Labor and Training (DLT) within 10 days of initial payment. Distribution: Original to DLT. Copy to the employee and his or her attorney by certified maoril sent with compensation check. Attachments: A wage statement for each employer and a dependencformy (unless both were attached to Non-Prejudicial Agreement) and a Report of Indemnity Payment (DWC-22). Definitions: PLEASE CHECK IF CORRECTION OF PRIOR REPORT: Check if sending in an amended form. 1. Employee: SSN: Employees Social Security Number. 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. Employer: FEIN: Employers Federal Employer Identification Number. Name: Employers actual name where the employee was employed at the time of the injury. Address (including city, state, zip) Addr:ess of the employers actual location. Phone/Ext: Phone number and extension (if necessary) of the employers facility. 3. Insurance company named on WC Policy: FEIN: WC Insurance companys Federal Employer Identification Number. Name: Name of the workers compensation insurer OR Self-Insu ifred the company has been certified as self-insured by DLT. Address (including city, state, zip) M: ailing address of the WC insurance carrier named on the WC Insurance Policy . Phone/Ext: Phone number and extension (if necessary) of the named WC insurance carri er. RI License Number Li:cense number issued by the RIDepar tment of Business Regulation (DBR) . 4. Claim Administrator: If this information is identical to the information in Block 3, check the Same box. If different, proceed below. FEIN: Federal Employer Identification Number of the company administering the claim. Name: 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. Phone/Ext: Phone number and extension (if necessary) of the claim administrator. RI License or Self-Insurance Number :License number issued by DBR or Self-Insurance Certificate number issued by DLT. Injury date: Date that the accident happened. First date of first disability: First full day that the employee lost from workduring the first period of disability for the injury. Place where injury occurred: City and State where injury took place. 5. Disability Type: Check the appropriate box(es) and enter incapacity date or approprte stariat date. Do not adjust date for three-day waiting period. Death Benefits/Date of Death Payable to: Date of death and name of eligible dependent to whom payment shall be made. 6. Rate Information: Single/Married: Check one. Number of Exemptions: Enter figure fromTotal Number of Exemptions box on Dependency formDW ( C-04). AWW (include bonus/no OT) E:nter average weekly wage that contains the averaged bonus amount, but not overtime (line 5 under Calculation of AWW on the full or part-time wage statements). Note: Adjust amounts throughout for multiple wage statements. Average Overtime Amount: Enter averaged overtime figure (line 6 underCalculation of A WW on the full or part-time wage statements) . AWW including Overtime: Enter total average weekly wage (line 7 under Calculation of AWW on the full or part-time wage statements) . Spendable Base Wage:E nter appropriate figure fromGr oss Wage to Spendable Earnings Table. Base Compensation Rate: Base compensation rate is 75 percent of the Spendable Base Wage, up to the maximum rate. Number of Dependents: Enter total number of dependents (not exemptions). Include non-working spouse. Weekly Dependency Rate: Total Incapacity Only. $15 per dependent or $40 per dependent for death claim . Total Weekly Rate Enter: total weekly compensation rate. Note: Comsation rate plus dependency rate pencannot exceed 80 percent of the total average weekly wage. Difference should show against the dependency rate on the Agreem ent.7. Date of Initial Payment: Enter the date of the first payment made under the Memorandum of Agreem ent. Other Employers/Recurrence block: Complete and attach appropriate information, if necessary . Signature/Date: Signature of the person who filled out the form and the date that the form was prepared. Print Name/RI Adjuster License Number/Phone & Extension: Clearly enter the name of the rson who filled peout the form, their RI Adjuster License Number as issued by the RI Department of Business Regulation, and the complete phone number of the preparer. Note: DO NOT ENTER SSN Request another number from DBR. <<<<<<<<<********>>>>>>>>>>>>> 2State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORT MEMORANDUM OF AGREEMEN T 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: 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 3FEIN 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 6. RATE INFORMATION: Single Married Number of Exemptions 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 RECEIV
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