Rhode Island > Workers Comp > Department Of Labor And Training > Claim
Report Of Earnings DWC-25 - Rhode Island
| Report Of Earnings Form. This is a Rhode Island form and can be used in Claim Department Of Labor And Training Workers Comp . |
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REPORT OF EARNINGS (DWC-25) General Instructions: Completed by: Claim Administrator and Employee. Time Frame: No set time frame. However, whether frisaud suspected or not, the Report of Earnings should be sent othue bt at eginning and end of each claim and at reasonae intervals throughout everybl ongoing claim. Distribution: Original from employee to claim administrator. DO NOT SENT TO DLT. Attachments: None, unless additional pages were required. Definitions: 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 Administrator or Self-Insured Employer: 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. This report cover the time period from/to PRESENT: After From, enter the first day that the employee lost from workdue to the injury. (Incapacity date) 3. NOTICE TO EMPLOYEES RECEIVING WORKERS COMPENSATION: Notice should be read completely. 4. Employee Complete: 1. State YES or NO: When answering the question, the emoyee pl must write in either Yes or No. 2. State YES or NO: When answering the question, the emoyee pl must write in either Yes or No. Employer Name: Name of employer providing the earnings, as listed in Section 3. Self-Employed?: Check appropriate box. Address(including city, state, zip, phone) Addr:ess and telephone number of emplopryer oviding the earnings, as listed in Section 3. Nature of BusinessGeneral classification of what the bus: iness does on a daily basis. (Ex. Restaurant; Jewelry Manufacturing; etc. )5. Earning Received: Date Earned/Amount: Enter the date the earnings were earned and the amount of earnings. Employee Signature/Date: Signature of employee and date form was signed. Witness Signature/Date: Signature of witness to employeesignaturs e and date form was signed. <<<<<<<<<********>>>>>>>>>>>>> 2State of Rhode Island REPORT OF EARNING S Department of Labor and Training, Division of Workers Compensation Phone (401) 462-8100 TDD (401) 462-8006 Insurer File No. 1. EMPLOYEE INFORMATION: 2. CLAIM ADMINISTRATOR: SSN FEIN Name Name Address Address City, State, Zip City, State, Zip Phone Phone Ext. This report covers the time period from: to: PRESENT 3. NOTICE TO EMPLOYEES RECEIVING WORKERS COMPENSATION: If you are receivingweeklyworkerscompensationbenefits,YOU MUSTREPORTANYEARNINGSYOU RECEIVETO THE CLAIMADMINISTRATOR THATIS PAYINGYOURBENEFITS.Earningsincludeanycash,wages,or salaryreceivedfromself-employmentorfromanyemployerotherthanthe employerwhereyou wereinjured. Earningsalso includecommissions,bonuses,and the cash valuefor all paymentsreceivedin any formotherthan cash (for example: a building custodian receiving a rent-free apartment ). Yourendorsementon a benefitcheckor depositof the checkinto an accountis yourstatementthat you are entitledto receiveworkerscompensationbenefits.Your signatureon a benefitcheckis a furtheraffirmationthat you have made no falseclaimsor statementsor concealedany materialfactregarding your workers compensation claim. Youmustreportany workfor anybusinessor person,evenif the businessor personlostmoneyorif profitsorincomewerereinvestedor paidto others.If youperformedanydutiesforanybusinessor personfor whichyouwerenotpaid,youmustshowa rateof payof whatit wouldhavecosttheemployer to hire someone to perform the work you did, even if your work was for y ourself, a relative, or friend. You are NOT entitled to workers compensation benefits for any time y ou are imprisoned as a result of a criminal conviction. 4. Employee Complete: 1. Did you receive earnings or payments during the above period? State YES or NO: 2. Did you perform non-paid work activities during the above period? Stat e YES or NO: If you answered NO to BOTH questions, sign, date and return the form to the CLAIM ADMINISTRATOR above. If you answered YES to EITHER question, complete the following: Employer Name Self-Employed? Yes No Address Nature of business City State Zip Code Phone 5. Earnings Received: Report pre-tax earnings. Include any cash, bonus, commission, and the c ash value of any payment received in any form other than cash. Attach additional pages if necessary. Date Earned: Amount: Date Earned: Amount: Date Earned: Amount: Date Earned: Amount: Failure to report earnings as defined will subject you to criminal prose cution and civil liability including the suspension or forfeiture of your benefits. This form MUST BE SIGNED, DATED and returned to the Claim Administrator -- EVEN IF YOU HAVE NO EARNINGS. Employee Signature: Date: Witness Signature: Date: DWC-25 (01/03) For instructions visit our web site: www.dlt.ri.gov/wc
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