Rhode Island > Workers Comp > Department Of Labor And Training > Claim
Report Of Specific Payment DWC-51 - Rhode Island
| Report Of Specific 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 SPECIFIC PAYMENT (DWC-51) General Instructions: Completed by: Claim Administrator Time Frame: The Report of Specific Payment should be filed withthe Depar tment of Labor and Training (DLT) within 10 days of payment. Payment must be mailed to claint within 14 daymas of the entry of a decree, order, or agreement of the parties. Distribution: Original to DLT. Attachments: None. Definitions: PLEASE CHECK IF CORRECTION OF PRIOR REPORT: Check if sending in an amended form. YOU MUST CHECK ONE OF THE FOLLOWING: Lost Time: Check if claimant received any weekly indemnity payments. No Lost Time: Check if claimant did not receive any weekly indemnity payments. Federal Jurisdiction: Check if claim was paid under Federal jurisdiction. 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. 5. Claim Information: Injury date: Date that the accident happened. Incapacity Date(if appropriate) Firs:t full day that the employee lost from work (include weekends and holiday s) . Average Weekly Wage (including OT)Clai: mants total average weekly wage. Weekly Specific Rate: Weekly rate used to pay specific. Specific paid by: Pretrial Order or Decree/Date/Number: Check appropriate box and enter date and Court-assigned number of document. Agreement of the Parties: Check if appropriate. Description of Injury/Specific: Describe what the specific payment is being made for. 6. Specific Payment Information : Indicate Payment Type/disfigurement or loss of use: Check appropriate box(es). Body Part: Enter appropriate part of body. Percent of Loss: Enter percentage of loss. Number of Week s: Enter number of weeks being paid for that entry. Amount Paid: Total amount paid for that entry. Date Paid: Enter payment date for that entry. Hearing Loss/ Left/Right Ear-Occupational/Traumatic: Check appropriate box(es). Total/Partial Deafness: Check appropriate box(es). Number of Week s: Enter number of weeks being paid for that entry. Amount Paid: Total amount paid for that entry. Date Paid: Enter payment date for that entry. Employee Signature (optional)/Date: If the Report has been paid byAgree ment of Parties, this allows the option for the claimant to sign and date. Employer/Insurer Signature/Date: Signature of employer or insurer and date prepared. <<<<<<<<<********>>>>>>>>>>>>> 2State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORT REPORT OF SPECIFIC PAYMEN 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) 462-8084 Insurer File No. YOU MUST CHECK ONE OF THE FOLLOWING: LOST TIME NO LOST TIME FEDERAL JURISDICTION 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 3 FEIN 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 5. CLAIM INFORMATION: Injury date Incapacity date (if appropriate) Average Weekly Wage (including OT) Weekly Specific Rate Specific paid by: Court Order Date: Number: OR Agreement of the PartiesDescription of Injury/Specific: Attorney Fee: 6. SPECIFIC PAYMENT INFORMATION: Indicate Payment Type Body Part Percent of Loss Number of Weeks Amount Paid Date Paid disfigurement loss of use disfigurement loss of use disfigurement loss of use Hearing Loss Total/Partial Deafness Number of Weeks Amount Paid Date Paid Left Ear occupational traumatic total partial Right Ear occupational traumatic total partial Employee Signature: Date: Employer/Insurer Signature: Date: (Not required for Court Order) DWC-51 (01/03) For instructions visit our web site: www.dlt.state.ri.us/wc
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