Fill and Sign the Rhode Island Compensation Form

DWC No:       Insurer's No:       Soc. Sec. No       Employer       Insurance Co.       Adjusting Co.       Injury date       Incapacity date       Date of death       Name       Address       City, State, Zip       Phone       Date of birth       No. of dependents       Maximum no. of exemptions ____ Married INTERIM AWW including overtime       Spendable base wage       Base compensation rate       Cost of living adjustment       Dependency rate       Total weekly compensation rate       TI PI DB                                     TI PI DB                                     TI PI DB                                     LOST TIME NO LOST TIME decree pretrial order preliminary det. mutual agreement                                                                                                                                                                                                                  Report of Payment State of Rhode Island Department of Labor and Training Division of Workers' Compensation P.O. Box 20190 Cranston, RI 02920-0942 Phone: (401) 462-8100 TDD: (401) 462-8084 EMPLOYEE INFORMATION: CLAIM INFORMATION: M F Single Indicate report type FINAL RATE INFORMATION: WEEKLY COMPENSATION: Indicat e Payment period Date from Payment periodDate through Number ofweeks & days If partial, Total weekly rate Compensation Payment type amount earned pai d --- --- --- SPECIFIC INJURY INFORMATION: Indicat e Number of Payment typePart of body Percent of loss week s Amount paid Paid by. disfig loss of use disfig loss of use disfig Date paid:- loss of use OTHER PAYMENTS: Indicate total paid to date. Payment type Amount paid Payment type Amount paid Payment type Amount paid Settlement Amount : Medical Buria l EE witness fee Decree No.: EE's atty fee Rehabilitation ER witness fee Decree Date: ER's atty fee Penalty Othe r Insurer Signature DWC-22 (06/00) Date