Fill and Sign the Rhode Island Compensation 497325283 Form

Yes N o SSN      Name       Address       City, State, Zip       Phone       FEIN       Name       Address       City, State, Zip       Phone             This report covers the time period from:             State YES or NO:       Did you perform non-paid work activities during the above period? State YES or NO:       Employer Name       Address       City                                                                                                                                                 Employee Signature       Date       Date             State of Rhode Island Department of Labor and Training Division of Workers' Compensation (401) 462-8100 TDD (401)462-8084 REPORT OF EARNINGS - This form is to be completed and returned to the Insurer Employee: Insurer or Self-Insured Employer: Ext . to: NOTICE TO EMPLOYEES RECEIVING WORKERS' COMPENSATION.- If you are receiving weekly workers' compensation benefits, YOU MUST REPORT ANY EARNINGS YOU RECEIVE TO THE INSURANCE COMPANY THAT IS PAYING YOU BENEFITS. ''Earnings" include any cash, wages, or salary received from self-employment or from any employer other than the employer where you were injured. Earnings also include commissions, bonuses, and the cash value for all payments received in any form other than cash (e.g. a building custodian receiving a rent-free apartment). Your endorsement on a benefit check or deposit of the check into an account is your statement that you are entitled to receive workers' compensation benefits. Your signature on a benefit check is a further affirmation that you have made no false claims or statements or concealed any material fact regarding your workers' compensation claim. You must report any work in any business, even if the business lost money or if profits or income were reinvested or paid to others. If you performed any duties in any business for which you were not paid, you must show a rate of pay of what it would have cost the employer to hire someone to perform the work you did, even if your work was for yourself, a relative, or friend. You are NOT entitled to workers' compensation benefits for any time you are imprisoned as a result of a criminal conviction. EMPLOYEE: COMPLETE THIS SECTION Did you receive earnings during the above period? . If you answered NO to BOTH questions, sign, date and return the form to the Insurer above. If you answered YES to EITHER question, complete the following: Self-Employed? State Zip Phone Earning received: Report pre-tax earnings. Include any cash, bonus, commission, and the cash value of any payment received in any form other than cash. Attach additional pages if necessary. Date Earned: Amount of Earnings: Date Earned: Amount of Earnings: Failure to report earnings as defined will subject you to criminal prosecution and civil liability including the suspension or forfeiture of your benefits. This form MUST BE SIGNED, DATED and returned to the Insurer EVEN IF YOU HAVE NO EARNINGS. Witness Signature DWC-25 (06/00)