Fill and Sign the Mutual Agreement Rhode Island Department of Labor and Form

$ $$ to effective date:toClaim Administrator Claim Number Employee Information Employer, Insurer & Claim Administrator Mutual 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 Last Name First Name Initial SSN or ID Date of Birth Date of Injury The injured worker and the Claims Administrator representing the Insurer and Employer agree on the specific injury or injuries stated here. This form may be used under RIGL § 28-35-6(b) to amend a Memorandum of Agreement, Order or Decree on a workers' compensation claim. This form cannot be used to start or end weekly benefits. Amendment to Memorandum of Agreement. Indicate the change. Change employee's marital status to Single Married Employer Business Name Insurer Business Name Date of Death Claim Administrator Business Name effective date: Change the total average weekly wage to Change the weekly spendable base wage to effective date:effective date: Change the weekly compensation rate to effective date:Change maximum number of eligible exemptionsChange number of dependents effective date: Modify from total to partial incapacity effective date: Modify from partial to total incapacity effective date: Suitable Alternative Employment (offer attached) effective date:Change nature of injury and/or affected body part toOther (specify) Specific Injury Agreement Disfigurement: Body Part Weeks Weekly Rate Amount Paid Date Paid Date Paid Loss of Use: Body Part Percent Weeks Amount PaidWeekly Rate Body Part Type of Hearing Loss Percent Weeks Weekly Rate Amount Paid Date Paid Left Occupational Traumatic Right Occupational Traumatic Both Occupational Traumatic DWC-24 1/2014 Signatures of Parties to this Agreement Employee Signature Date Claim Adjuster Signature Date 0.00% 0.00% 0.00% 0.00% 0.00% Mutual Agreement (DWC-24 1/2014) Page 1 A Mutual Agreement is a legal document that me morializes an agreement between the parties to change a Memorandum of Agreement as specified in RI GL § 28-35-6(b). A copy is provided to each party and filed with RI Department of Labor and Training. 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.  Date of birth: please enter the employee’s date of birth.  Name: enter the employee’s last name, first name and middle initial.  Date of injury: enter the date of the injury or start of illness.  Date of death: if the employee has died, enter the date of death. Employer, Insurer and Claim Administrator information:  Employer Business Name: enter the name of the employer’s business.  Insurer Business Name: enter the name of th e licensed insurance company or self-insured employer.  Claim Administrator: enter the business name of the company handling the claim. Amendment to Memorandum of Agreement.  Indicate the agreed upon changes us ing the options listed on the form.  Provide complete information for each change including amounts and dates as indicated  Indicate any other amendment not listed on the form and specify the change. Specific Injury Agreement  Provide the details of any agreement on compensation for specific injuries. Use a separate line for each body part.  Disfigurement: provide the disfigured body part, number of weeks of payment, weekly payment rate, total amount of the payment, and the date the payment is made.  Loss of use: indicate the affected body part, percent of loss, number of weeks of payment, weekly payment rate, total amount of the paym ent, and the date the payment is made.  Hearing Loss: indicate if hearing loss is for left, right or both ears. Specify the type of hearing loss as occupational or traumatic. Provide th e percent of loss, number of weeks of payment, weekly payment rate, total amount of the pa yment, and the date the payment is made. Signature Block. Both the employee and a representa tive for the claims administrator on behalf of the employer must sign this document and date the form. A copy of the form must be provided to each party and filed with RI Department of Labor and Training. Revised 12/12/2016