Rhode Island > Workers Comp > Department Of Labor And Training > Claim
Wage Transcript DWC-30 - Rhode Island
| Wage Transcript Form. This is a Rhode Island form and can be used in Claim Department Of Labor And Training Workers Comp . |
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WAGE TRANSCRIPT (DWC-30) General Instructions: Completed by: Insurer and employees return-to-work employer. Time Frame: No set time frame. However, if the insurer/employer cannot obtain a Suspension Agreement and Recei frptom the employee and he or she has been back to work at least two consecutive weeks equal to or in excess of their average weekly wage, not including overtime, a Wage Transcript can be used to close the claim. Distribution: Original to Department of Labor and Training. Copy to employee and/or the employees legal representative. Attachments: None. 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). 3. Insurer Complete: Discontinuation of benefits/Reduction of benefits: Check appropriate box. Date benefits were discontinued or reduced: Date the employee returned to work. Pre-injury average weekly wage, not including overtime: Enter average weekly wage that contains the averaged bonus amount, but not overtime. 4. Employer Complete: Post-Injury Earning Information: Period Start Date: Beginning date of the earnings period. Period End Date: Ending date of the earnings period. Number of Hours Worked: Number of hours worked during the pay period listed. Payment Rate: Hourly or salary rate for payment period listed. Amount of Earnings A: mount paid for the payment period listed. Employer Name: Name of actual employer where wages were earned. Address(including city, state, zip, phone) Addr:ess and telephone number ofplo emyer where the wages were earned. Employer Signature/Date: Signature of the employers Treasurer orher otappropriate official and the date prepared. <<<<<<<<<********>>>>>>>>>>>>> 2State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORTWAGE TRANSCRIP T Department of Labor and Training, Division of Workers Compensation DWC No.PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (40 1) 462-8006 Insurer File No. This form will not be accepted for filing unless all information is comp leted.1. EMPLOYEE INFORMATION: 2. CLAIM INFORMATION: SSN Employer Name Insurance Co. Address Claim Administrator City, State, Zip Injury date Phone Incapacity date 3. INSURER COMPLETE: This wage transcript is submitted to support a: Discontinuation of benefits. The employee has returned to work at a wage equal or greater than he o r she earned at the time of the injury. Reduction of benefits. The employee has returned to work at a wage less than he or she earned at the time of the injury. Date benefits were discontinued or reduced: Pre-injury average weekly wage, not including overtime: 4. EMPLOYER COMPLETE: Post-Injury Earning Information -- WEEKS MUST BE CONSECUTIVE Number of Amount of Period Start Date Period End Date Payment Rate Hours Worked Earnings Week 1 Week 2 Employer Name: Address: City, State Zip: Phone: Employer Signature: Date: DWC-30 (01/03) For instructions visit our web site: www.dlt.ri.gov/wc
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