Itemized Statement Of Compensation {DWC-50}

State of Rhode Island ITEMIZED STATEMENT OF COMPENSATION 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. Phone (401) 462-8100 TDD (401) 462-8006 1. EMPLOYEE INFORMATION: SSN Name Address City, State, Zip 2. CLAIM INFORMATION: Employer Insurance Co. Claim Administrator Injury date Date of death Incapacity date Work-related OR Not All others continue below. 3. Incident Only--No payments made. Complete Section 8 and return to DLT only at above address. 4. NONPAYMENT OF WEEKLY INDEMNITY ONLY: Check correct box and complete appropriate information on remainder of form. Medical Only* *Payment info must be listed below Federal Jurisdiction Salary Continuation Other: Denied Death--Liability established; no dependents. Payment made to WCAF Do NOT use Other if claim is Denied 5. DIAGNOSIS: Primary Written Diagnosis Secondary Written Diagnosis (List total amount paid for each appropriate item in both columns) ICD Code: ICD Code: 6. PAYMENT INFORMATION: Temporary Partial Temporary Total Permanent Total Weekly Death Benefits Burial Specific - Disfigurement Specific - Loss of Use Vocational Rehabilitation Physical Therapy Occupational Therapy Psychological Services Physicians 7. RETURN TO EMPLOYMENT: If yes, was it with the DATE OF FIRST INDEMNITY PAYMENT: Hospital/Treatment Center Independent Medical Exams Pharmaceutical Chiropractic Diagnostic Testing Attorney Fees Awarded by Court Penalties/Interest WC Administrative Fund (WCAF) Settlement Deny & Dismiss Other Payments: Subrogation Did the employee return to employment? different employer Unknown Yes Yes No No Unknown Unknown same employer OR a Date Returned: 8. THIS REPORT WAS PREPARED BY: Name Company Name Address City Telephone Signature DWC-50 (01/03) PLEASE PRINT RI Adjuster License Number State Extension Zip Code Email Date Distribution: DLT, Division of Workers' Compensation; Employee and Attorney; Employer For instructions visit our web site: www.dlt.ri.gov/wc American LegalNet, Inc. www.FormsWorkFlow.com