Fill and Sign the Certificate of Dependency Form Dwc 04 Rhode Island

Injured body part & nature of injuryCity, State Zip Permanent Total Start Date First Payment Issue Date First Date of Disability Temporary Partial Start Date Insurer Information Claim Administrator Information (Adjusting Company) Claims Adjuster Signature Printed Name DateDeath Benefits Paid to Does the employee have other employers? No Signature Date of Death Other information Base Compensation Rate Total Weekly Rate FEIN Injury Information Date of Injury Business NameAddressCity, State ZipPhone Date of Birth Notice to Employees Receiving Worker's Compensation Benefits Rate Information Single Married Number of Exemptions (self, spouse & children) Employee's Marital Status SSN or IDNameAddressCity, State Zip Claim Administrator Claim Number Non-Prejudicial Agreement RI Department of Labor and Training, Division of Workers' Compensation PO Box 20190, Cranston, RI 02920-0942 www.dlt.ri.gov/wc Phone 401-462-8100 Fax 401-462-8105 Employer Information Employee Information Temporary Total Start Date Yes DWC-20 06/2014 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 compañía aseguradora NO se hacen legalmente responsables de su lesión en el trabajo. Tiene dos (2) años para entablar una demanda en el Tribunal de Compensación Laboral para establecer la responsabilidad. Yes FEIN Business NameAddress Phone Phone FEIN Business NameAddressCity, State Zip Death Benefits Start Date Place where injury occurred Disability Information Spendable Base Wage Weekly Dependency Rate Number of Dependents (children & nonworking spouse)Total Average Weekly Wage Attach 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. YesNo No Previous disability end date: Non-Prejudicial Agreement (DWC-20 6/2014) Page 1 RIGL § 28-35-8 requires the insurer to file a No n-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 St atus (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 cl aim number or file identification number for the company handling the claim: the insurer, self-insur ed employer or third party administrator. Employee information:  SSN or ID: Provide at least the last 4 digits of the employee’s social security number or the employee ID number assigned by DLT. DO NOT use a fictitious number. Please contact RI DLT to obtain an assigned employee ID number.  Name: enter the employee’s first name, middle initial and last name.  Address: give the employee’s mailing address, city, state and zip.  Date of birth: enter the employee’s date of birth. Employer information: Please provide the empl oyer’s Federal Employer Identification Number, employer business name, employer busin ess mailing address and phone number. Insurer information: Provide the information for the licensed insurer named on the workers’ compensation policy or the self-insured employ er’s 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 employee’s injured body parts. Examples: cut right index finger, fractured right wrist or sprained lower back. Rate Information:  Employee’s 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 numbe r of employee’s dependents including non- working spouse and dependent children. A ch ild is dependent through age 18, or through age 23 if a full-time student. A disabled child is dependent at any age. See RIGL § 28-35-1.  Number of Exemptions: enter the maximum number of exemptions the employee can claim for tax purposes. Count the emplo yee and his or her dependents and any other person who qualifies as an ex emption for tax purposes. Non-Prejudicial Agreement (DWC-20 6/2014) Page 2  Total Average Weekly Wage: enter the amount of the total average weekly wage (AWW) as calculated on the Wage Statement (DWC-03).  Spendable Base Wage: calculate the Spendable Base Wage using the formulas or tables on the DLT web site.  Base Compensation Rate: Multiply the Spenda ble Base Wage by 75% to calculate the base compensation rate. The rate can be no hi gher than the annual maximum compensation rate.  Weekly Dependency Rate: Enter the total week ly amount of dependency allowance, up to 80% of total AWW as allowed in RIGL § 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 this disability period.  First Date of Disability: Enter the start date of the first disability period for this injury including the waiting period (the first day of the waiting period).  Temporary Total Start Date: Enter the first date the employee is owed temporary total disability benefits for this period of disability. If this is the first period of disability, this would 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 partial disability benefits for this period of disability. If this is the first period of disability, this would 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 employee’s survivors are due death benefits.  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 each employer is needed.  Is this a recurrence of a previous injury? Check yes or no.  Previous disability end date: enter the last da te of the previous disability to show if 26 weeks have passed since the prev ious disability period ended.  Did the employee work 26 weeks or more before th is recurrence? Check yes or no. If yes, a new wage statement must be complete d 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 employee’ s attorney and the DLT within 10 days of the first payment issue date. Revised 12/12/2016