Report Of Specific Payment {DWC-51}

State of Rhode Island REPORT OF SPECIFIC PAYMENT Department of Labor and Training, Division of Workers' Compensation PO Box 20190, Cranston, RI 02920-0942 PLEASE CHECK IF CORRECTION OF PRIOR REPORT DWC No. Insurer File No. FEDERAL JURISDICTION Phone (401) 462-8100 TDD (401) 462-8084 YOU MUST CHECK ONE OF THE FOLLOWING: LOST TIME 1. EMPLOYEE: SSN Name Address Address City, State, Zip Phone FEIN Name Address Address City, State, Zip Phone RI License Number NO LOST TIME 2. EMPLOYER: FEIN Name Address Address City, State, Zip Phone Date of Birth Ext. 3. INSURANCE COMPANY NAMED ON WC POLICY: 4. CLAIM ADMINISTRATOR: FEIN Name Address Address City, State, Zip Phone RI License or Self-Insurance Number Incapacity date (if appropriate) Weekly Specific Rate SAME AS BLOCK 3 Ext. Ext. 5. CLAIM INFORMATION: Injury date Average Weekly Wage (including OT) Specific paid by: Court Order Date: Number: OR Agreement of the Parties Description of Injury/Specific: Attorney Fee: 6. SPECIFIC PAYMENT INFORMATION: Indicate Payment Type disfigurement disfigurement disfigurement loss of use loss of use loss of use Hearing Loss Left Ear Right Ear occupational occupational traumatic traumatic Total/Partial Deafness total total partial partial Number of Weeks Amount Paid Date Paid Body Part Percent of Loss Number of Weeks Amount Paid Date Paid Employee Signature: (Not required for Court Order) Date: Employer/Insurer Signature: Date: DWC-51 (01/03) For instructions visit our web site: www.dlt.state.ri.us/wc American LegalNet, Inc. www.FormsWorkFlow.com