Fill and Sign the Memorandum Agreement Contract Form

Single Married Exemptions Yes No Yes No Previous disability end date Yes No If yes, a new wage statement is required.                                                                                                                                                                                                Temporary Partial as of Temporary Total as of       Death Benefits. Date of Death             Payable to:       Permanent Total as of             AWW without overtime       Avg, Overtime Amount       AWW including Overtime       Spend able Base Wage       Base Compensation Rate       Cost Of Living Adjustment       Number of Dependents       Weekly Dependency Rate       Total Weekly Rate                         State of Rhode Island Department of Labor and Training, Division of Workers' Compensation P.O. Box 20190, Cranston, RI 02920-0942 (401) 462-8100 TDD (401) 462-8084 Memorandum of Agreement Employee:DWC File No. Employer: SSN Name FEI N Addres s Name Addres s Phone Phone Ext. Date of Birth Policy No. Insurer: Adjusting Company: FEIN FEIN Name Name Address Address Phone Ext. Phone Ext. Insurer File No. Adjusting Company File No. Injury Dat e First Date of First Disability Nature of injury and injured body part: Place where injury occurred: DISABILITY TYPE: (check all that apply) RATE INFORMATION. Does employee have other employers? If Yes, attach a wage statement from each employer. Is this a recurrence of a previous injury? worked at least 26 weeks prior to this recurrence. Has the employee Pursuant to R-I.G.L S 28-35-1, a Memorandum of Agreement (MOA) must be filed with the Department of Labor and Training within 10 days Of initial payment. A dependency form and wage statement for each employer must be attached as amendments. The MOA becomes binding upon filing. A copy of the MOA with its amendments must be mailed to the employee and his/her attorney by certified mail, return receipt requested, at the time it is filed with the Department of Labor and Training. Insurer Signature Dat e NOTICE TO EMPLOYEES RECEIVING WORKERS' COMPENSATION BENEFITS: YOU MUST REPORT ANY EARNINGS you receive to the insurer that pays your benefits. Failure to report earnings may subject you to civil or criminal liability. Your endorsement on a benefit check is your statement that you are qualified to receive workers' compensation benefits. You are NOT entitled to receive workers' compensation benefits for any time that you are imprisoned as a result of a criminal conviction. DWC-02 (06/00)