Fill and Sign the Employee Complete This Form and Return it to the Claim

Check if this is a corrected report · · DWC-04 (2/13) Date Employee's SignatureYes NoNo Yes Yes Yes No No SSN: XXX - XX - Employee: complete this form and return it to the Claim Administrator. This information is needed to calculate your compensation rate. Phone Date of Birth No 3. Marital Status City, St, Zip Married Spouse's name Spouse does not work Spouse works 5. Dependents A dependent for workers' compensation includes children you support who are:Address Address City, St, Zip Under age 18, or age 18 to 23 and a full time student 4. Number of Federal Exemptions Enter the maximum number of Federal Exemptions you are allowed to claim for Federal income tax. Include yourself, your spouse, your dependents, and any other exemptions. Name Claim Administrator Mentally or physically incapacitated from earning at any age Yes Date of Birth Employee's Certificate of Dependency Status No State of Rhode Island Employer name 1. Employee information: 2. Claim information: No No No Yes Yes Yes At the time of the injury the employee was Single Relationship Injury Date Incapacity Date Dependent's Name Full time student? Yes Department of Labor and Training, Division of Workers' Compensation PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 Claim Administrator File Number: Employee’s Certificate of Dependency Status (DWC-04 2/2013) Page 1 An Employee’s Certificate of Dependency Status is required with a Memorandum of Agreement or a Nonprejudicial Agreement to verify marital status, maximum number of federal exemptions, and number of dependents for calculation of weekly benefits. The claim administrator (the company handling the claim: the insurer, self-insured employer or third party administrator) completes sections 1 and 2 of the form. The employee completes the rest of the form, signs it, and returns the form to the claim administrator. The claim administrator sends the form to the DLT as part of a Nonprejudicial Agreement, Memorandum of Agreement, or as required by court order or decree. Top of form:  Correction Box: Check if this document is correcting a document previously filed.  Claim Administrator File Number: Provide the claim number or file identification number for the company handling the claim: the insurer, self-insured employer or third party administrator. 1. Employee Information. The claim administrator completes section 1.  SSN: provide at least the last 4 digits of the employee’s social security number or the employee ID number assigned by RIDLT. 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: complete the employee’s street address, city, state, and zip code.  Phone: provide the employee’s phone number if available.  Date of Birth: enter the employee’s date of birth if available. 2. Claim Information. The claim administrator completes section 2.  Employer name: enter the company name of the injured worker’s employer.  Claim Administrator: enter the company name of the party handling the claim.  Address: complete the mailing address for the claim administrator.  Injury date: enter the injury date.  Incapacity date: Enter the incapacity date, which is the first full day that the employee was unable to work. 3. Marital Status. The employee completes section 3.  Check the single box if you are unmarried, widowed or divorced. Check the married box if you are married or separated.  If you are single, leave the rest of section 3 blank.  Check “Spouse works” if your spouse is employed or “Spouse does not work” if not. A non-working spouse qualifies as a dependent for workers’ compensation.  Enter your spouse’s name. 4. Number of Federal Exemptions. The employee completes section 4.  Enter the maximum number of exemptions you are allowed to claim for Federal income tax. This includes you, your spouse, your dependent children, and any other exemptions.  Dependents for workers’ compensation include children you support who are under age 18, full time students to age 23, or mentally or physically incapacitated from earning at any age. Employee’s Certificate of Dependency Status (DWC-04 2/2013) Page 2  A child may qualify as an exemption for Federal income tax even if the child does not qualify as a dependent for worker’ compensation. Contact your claim administrator if you are allowed to claim any other exemptions for Federal income tax besides yourself, your spouse, and children who qualify as dependents for workers’ compensation. 5. Dependents. The employee completes section 5.  List your dependent children, one on each line.  Include the dependent’s first and last name, date of birth, and relationship to you.  Check YES or NO to show if the dependent is a full time student. The employee must sign and date the form and return the form to the claim administrator. The claim administrator sends the form to the Department of Labor and Training as part of a Nonprejudicial Agreement, Memorandum of Agreement, or as required by court order or decree. Revised 12/12/2016