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Report Of Indemnity Payment DWC-22 - Rhode Island
| Report Of Indemnity Payment 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 INDEMNITY PAYMENT (DWC-22) General Instructions: Completed by: Claim Administrator. Time Frame: As a Termination of Benefits under Non-udicial PrejAgreement: Within ten days of the termination of benefits. As a payment under Memorandum of Agreement (MOA): Initial report should be attached to MOA. Additional reports are due every six months on an ongoing claimor any time there is any change in the competion rnsa ate (i.e. COLA or change in dependents). Distribution: Original to Department of Labor and Training. When used as a Termation of Beinnefits under Non-Prejudicial Agreement, copies must be sent to employee and his or her attorney within ten days of the termination of payments. Attachments: When submitting a final payment report under an MOA, a Suspension Agreement and Receipt (DWC-5) should be attached. Definitions: PLEASE CHECK IF CORRECTION OF PRIOR REPORT: Check if sending in an amended form. YOU MUST CHECK ONE OF THE FOLLOWING: Termination of Benefits Under Non-Prejudicial Agreement: Check only when ending benefits under a Non-Prejudicial Agreement. Payment under Memo of Agreement, Order or Decree: Check when appropriate. YOU MUST CHECK ONE OF THE FOLLOWING: Report type: Final or Interim:Check Interim when weekly indemnity payments will continue. Check Final when weekly indemnity payments have ended. Termination of Benefits will alwaysF be a inal. If final, date of last weekly indemnity payment: Enter the date of the last weekly indemnity check. 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 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. 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 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). Date of Death: Conditional, if employee died Check box if death was NOT work-related. 3. Rate Information: AWW including Overtime: Enter appropriate figure as listed on Agreement, Order or Decr ee. Spendable Base Wage: Enter appropriate figure as listed on Agreem ent. Base Compensation Rate: Enter appropriate figure as listed on Agreem ent. AWW (include bonus/no OT) E:nter appropriate figure as listed on Agreem ent. Total Cost of Living Adjustment(s )If clai:mant is entitled, enter total cumulative amount calculated for Cost of Living Adjustment. Weekly Dependency Rate: Total Incapacity Only. $15 per dependent or $40 per dependent for death claim . 4. Weekly Compensation: Indicate Payment Type: TI: Total Incapacity PI: Partial Incapacity DB: Death Benefits Payment period Date from: Date of Incapacity (first full day without wages). notDo adjust date for three-day waiting period. Payment period Date throug Lh: ast date of the benefit perod fori which benefits were paid. Number of Weeks & Days: Number of weeks and days that the payment resents.epr Three-day waiting period may be deducted here. Total Weekly Rate Total :weekly compensation rate used. Variable Partial Total Spendable: Only use when paying variable or workingtial. par Total amount of Spendable Earnings for the weeks of variable partial as listed in Section 5 of this form. SeCalculatioe n of a Variable Partial for more information. Compensation Paid: Total compensation paid. Settlement/Deny & Dismiss: Enter amount of settlement or D&D, WCourt Decree nuC mber, and date of Decree. 5. Weekly Compensation for Variable Partial Payments: Week Ending:W eek ending date for the Gross Earnings listed. Gross Earnings: Total weekly gross earnings of claimant. Spendable Base Wage: Enter appropriate figure fromGr oss Wage to Spendable Earnings Table. Note: If paying Suitable Alternative Employment (SAE) write SAE in the Spendable Eings coluarnmn and complete other columns as noted. Amount Paid: Amount paid by the claim administrator for that week. 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 ent er the name of the person who filled out 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 REPORT OF INDEMNITY PAYMENT 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. YOU MUST CHECK ONE OF THE FOLLOWING: MUSTYOU CHECK ONE OF THE FOLLOWING: TERMINATION OF BENEFITS UNDER NON-PREJUDICIAL AGREEMENT* INTERIM PAYMENT UNDER MEMO OF AGREEMENT, ORDER OR DECREE FINAL:Date of last weekly indemnity payment: 1. EMPLOYEE INFORMATION: 2. CLAIM INFORMATION: SSN Employer Name Insurance Co. Address Claim Administrator City, State, Zip Injury date Phone Date of Birth Incapacity date Maximum no. of exemptions ________ Single Married Date of death NOT work-related3. RATE INFORMATION: AWW including Overtime AWW (include bonus/no OT) Spendable Base Wage Total Cost of Living Adjustment(s) Base Compensation Rate Weekly Dependency Rate 4. WEEKLY COMPENSATION: Indicate Payment period Payment period Number of Total Variable Partial Compensation Settlement Payment Type Date from Date through Weeks & Days Weekly Rate Total Spendable Paid Deny&Dismiss Amount: TI PI DB Decree No. TI PI DB Decree Date TI PI DB 5. WEEKLY COMPENSATION for Variable Partial Payments: (Complete information above also) Spendable Spendable Week Ending Gross Earnings Amount Paid Week Ending Gross Earnings Amount Paid Earnings Earnings Signature: Date: Print Name: RI Adjuster License Number: Phone & Extension: *THE FOLLOWING NOTICE IS FOR EMPLOYEES TERMINATED UNDER A NON-PREJUDICIAL AGREEMENT ONLY Weekly compensation payments have stopped. The insurer/employer has not accepted liability for this claim. If you wish to protect any rights you may have under the Workers Compen
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