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Suspension Agreement And Receipt DWC-05 - Rhode Island
| Suspension Agreement And Receipt Form. This is a Rhode Island form and can be used in Claim Department Of Labor And Training Workers Comp . |
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SUSPENSION AGREEMENT AND RECEIPT (DWC-05) General Instructions: Completed by: Employer/Insurer and Employee. Time Frame: No set time frame. However, the Suspension should be submitted as soon as possible after the end of weeklydem innity payments made under a Memorandum of Agreement (MOA). Claim isconsider not ed closed unless this form is filed with DLT. (See Wage Transcript instructions) NOTE: Do not use a Suspension when paym entswere only made under a on-N Prejudicial Agreement. Distribution: Original to Department of Labor and Training. Copy to each of the parties. Attachments: When submitting afinal Report of Indemnity Payment (DWC-22) underan M OA, a Suspension should be attached. 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. Phone: Employees current home telephone number. 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 carrr,ie 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). We agree that: Enter the date of incapacity as defined above and the date that the weeklyindem nity payments were made through. Employee Signature/Date Employer/Insurer Signature/Date: Both parties must sign and date this form. <<<<<<<<<********>>>>>>>>>>>>> 2State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORTSUSPENSION AGREEMENT AND RECEIP 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 INFORMATION: 2. CLAIM INFORMATION: SSN Employer Name Insurance Co. Address Claim Administrator City, State, Zip Injury date Phone Incapacity date We agree that weekly compensation which began on ____________________(dateof incapacity) will end as of ____________________(datepaid through). Payment of medical bills related to this injury may continue. Completing and signing this form does not prevent the employee from claiming future weekly compensationbenefits in the event that the employee is unable to work due to this injury. Employee Signature: Date: Employer or Insurer Signature: Date: DWC-05 (01/03) For instructions visit our web site: www.dlt.ri.gov/wc
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