Non Prejudicial Agreement {DWC-20}

Injured body part & nature of injuryCity, State ZipPermanent Total Start DateFirst Payment Issue DateFirst Date of DisabilityTemporary Partial Start DateInsurer InformationClaim Administrator Information (Adjusting Company)Claims Adjuster SignaturePrinted Name DateDeath Benefits Paid toDoes the employee have other employers?NoSignatureDate of DeathOther informationBase Compensation RateTotal Weekly RateFEINInjury InformationDate of InjuryBusiness NameAddressCity, State ZipPhoneDate of BirthNotice to Employees Receiving Worker's Compensation BenefitsRate InformationSingleMarriedNumber of Exemptions (self, spouse & children)Employee's Marital StatusSSN or IDNameAddressCity, State ZipClaim Administrator Claim NumberNon-Prejudicial AgreementRI Department of Labor and Training, Division of Workers' CompensationPO Box 20190, Cranston, RI 02920-0942 www.dlt.ri.gov/wc Phone 401-462-8100 Fax 401-462-8105Employer InformationEmployee InformationTemporary Total Start DateYes DWC-20 0/201 ATTENTION: The employer and insurer are NOT accepting legal responsibility for your work injury. You have two (2) years to file a petition at the Workers' Compensation Court to establish liability.ATENCION: El empleador y la compa361355a aseguradora NO se hacen legalmente responsables de su lesi363n en el trabajo. Tiene dos (2) a361os para entablar una demanda en el Tribunal de Compensaci363n Laboral para establecer la responsabilidad.YesFEINBusiness NameAddressPhonePhoneFEINBusiness NameAddressCity, State ZipDeath Benefits Start DatePlace where injury occurredDisability InformationSpendable Base WageWeekly Dependency RateNumber of Dependents (children & nonworking spouse)Total Average Weekly WageAttach a completed wage statement for each employer.Is this a recurrence of a previous injury?Did the employee work 26 weeks or more before this recurrence?If so, a new wage statement is required.YesNoNoPrevious disability end date: American LegalNet, Inc. www.FormsWorkFlow.com Non-Prejudicial Agreement (DWC-20 /201) Page 1 RIGL 247 28-35-8 requires the insurer to file a Non-Prejudicial Agreement with The Department of Labor and Training (DLT) when indemnity benefits are paid voluntarily without liability. A Wage Statement (DWC-03) and Certificate of Dependency Status (DWC-04) must be submitted as part of the agreement. A copy of the agreement must also be sent to the employee and his or her attorney. As of March 1, 2015, the insurer must also submit an electronic Subsequent Report of Injury to DLT when benefits begin. Claim Administrator Claim Number: Provide the claim number or file identification number for the company handling the claim: the insurer, self-insured employer or third party administrator. Employee information: SSN or ID: Provide at least the last 4 digits of the employee222s social security number or theemployee ID number assigned by DLT. DO NOT use a fictitious number. Please contact RIDLT to obtain an assigned employee ID number.Name: enter the employee222s first name, middle initial and last name.Address: give the employee222s mailing address, city, state and zip.Date of birth: enter the employee222s date of birth.Employer information: Please provide the employer222s Federal Employer Identification Number, employer business name, employer business mailing address and phone number. Insurer information: Provide the information for the licensed insurer named on the workers222 compensation policy or the self-insured employer222s name. Include the insurer business name, insurer mailing address and phone number. Claim Administrator information: Supply information for the company handling the claim. Provide the claim administrator business name, mailing address, and phone number. Injury Information: Date of injury: enter the date of the injury or start of illness.Place where injury occurred: enter the city and state where the injury occurred.Injured body part & nature of injury: list the nature of each injury and the employee222sinjured body parts. Examples: cut right index finger, fractured right wrist or sprained lowerback.Rate Information: Employee222s marital status: check single if the employee is unmarried, divorced or widowed.Check married if the employee is married or separated.Number of Dependents: enter the number of employee222s dependents including non-working spouse and dependent children. A child is dependent through age 18, or throughage 23 if a full-time student. A disabled child is dependent at any age. See RIGL 247 28-35-1.Number of Exemptions: American LegalNet, Inc. www.FormsWorkFlow.com Non-Prejudicial Agreement (DWC-20 6/2014) Page 2 Total Average Weekly Wage: enter the amount of the total average weekly wage (AWW) ascalculated on the Wage Statement (DWC-03).Spendable Base Wage: calculate the Spendable Base Wage using the formulas or tables onthe DLT web site.Base Compensation Rate: Multiply the Spendable Base Wage by 75% to calculate the basecompensation rate. The rate can be no higher than the annual maximum compensationrate.Weekly Dependency Rate: Enter the total weekly amount of dependency allowance, up to80% of total AWW as allowed in RIGL 247 28-33-17 (c) (1).Total Weekly Rate: Enter the total weekly compensation rate including dependency.Disability Information: First Payment Issue Date: Enter the date the first indemnity payment was issued for thisdisability period.First Date of Disability: Enter the start date of the first disability period for this injuryincluding the waiting period (the first day of the waiting period).Temporary Total Start Date: Enter the first date the employee is owed temporary totaldisability benefits for this period of disability. If this is the first period of disability, thiswould be the first day after the waiting period. If this is a subsequent period of disability, this is the first day of this subsequent period.Temporary Partial Start Date: Enter the first date the employee is owed temporary partialdisability benefits for this period of disability. If this is the first period of disability, thiswould be the first day after the waiting period. If this is a subsequent period of disability, this is the first day of this subsequent period.Death Benefits Start Date: Enter the first date the employee222s survivors are due deathbenefits.Date of Death: If the employee has died, enter the date of death.Death Benefits Paid to: Enter the name of the primary survivor receiving death benefits.Other Information: Does the employee have other employers? Check yes or no. A wage statement from eachemployer is needed.Is this a recurrence of a previous injury? Check yes or no.Previous disability end date: enter the last date of the previous disability to show if 26weeks have passed since the previous disability period ended.Did the employee work 26 weeks or more before this recurrence? Check yes or no. If yes, anew wage statement must be completed based on this new disability date. Signature Block. The claim adjuster must sign this document, print name and date the form. Send the document to the employee, the employee222s attorney and the DLT within 10 days of the first payment issue date. Revised /201 American LegalNet, Inc. www.FormsWorkFlow.com