COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. ITEMIZED STATEMENT OF COMPENSATION : Calendar No. (DWC-50) : JUDICIAL General Instructions: Plaintiff(s) -againstCompleted by: Claim Administrator. Time Frame: SUBPOENA : Within 60 days after the discontinuance or suspension of compensation payments. : Distribution: Original to Department of Labor and Training (DLT). Copy to the employee and his or her attorney and also to the employer, if filed by the insurer. : Attachments: None. Defendant(s) : . .Definitions:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......... PLEASE CHECK IF CORRECTION OF PRIOR REPORT: Check if sending in an amended form. 1. Employee Information: SSN: Employee’s Social Security Number. Name: Employee’s full name. THE PEOPLE(including city, state, zip): Employee’s YORK Address OF THE STATE OF NEW current mailing address. 2. Claim Information: Employer: Name of company where the employee was employed at the time of the injury. TO Insurance Co.: Name of the worker’s compensation insurer OR ‘Self-Insured’ if the company has been certified as self-insured by DLT. Claim Administrator: Name of the WC insurance carrier, third party administrator, or self-insured employer responsible for administering the claim. Injury Date: Date that the accident happened. Incapacity Date: First full day that the employee lost from work (include weekends and holidays). Date of Death: Conditional, if employee died – Check appropriate box as to whether death was work-related or not. GREETINGS: 3. Incident Only: Check this box if no payments were made on the claim. Complete Section 8 and return to DLT only. WE COMMAND YOU, 4. Nonpayment of Weekly Indemnity Only: that all business and excuses being laid aside, you and each of you attend before Medical the claim the Honorable Only: Check if medical payment(s) were made on at the but NO weekly indemnity. Court Federal Jurisdiction: Check if claim fell under Federal Jurisdiction for weekly indemnity. located continued for employee. County of Continuation: Check if full salary was at Salary in room Denied: Check if claim was denied by Claim Administrator. 20 , on the day of , , at o'clock in the noon, and at any recessed Death: Check if there were or adjourned date, todeath was and give evidence as no witness is under another state’s the part of the been sent to RI by testify work-related and for example,aifdependents. this action on jurisdiction and had in Other: Use only if none of the above apply; the claim mistake. 5. Diagnosis: Primary Written Diagnosis: Enter the primary written diagnosis supplied by medical provider. ICD Code: International (Statistical) Classification of Diseases (and Related Health Problems) code should be supplied by medical Your provider. failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Secondary Written Diagnosis: subpoena was issued for a maximum by medical provider. the party on whose behalf thisEnter the secondary written diagnosis, if any, providedpenalty of $50 and all damages sustained as a result ofICD Code: International (Statistical) Classification of Diseases (and Related Health Problems) code should be supplied by medical your failure to comply. provider. 6.Payment Information: For each and every item where payment was made, enter the total amount paid. In the case of Subrogation, check Yes or No as to whether or not the claim was subrogated. Witness, Honorable , one of the Justices of the Date of First Indemnity Payment: Enter the date the first indemnity payment was made. 7. Return Court in to Employment: Please complete all requested information. , 20 County, day of 8. This Report was Prepared by: PRINT ALL INFORMATION Name: Print full name of person who filled out the form (report preparer). RI Adjuster License Number: Enter RI Adjuster License Number as issued by the RI Department of Business Regulation. Note: DO NOT ENTER SSN – Request another number from DBR. Company Name: Name of the company where the report preparer is employed. (Attorney must sign above and type name below) Address (including city, state, zip): Mailing address of the company where the report preparer is employed. Phone/Ext/Email: Phone number and extension (if necessary) and email address of the report preparer. Signature/Date: Signature of the person who filled out the form and the date that the form was prepared. Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORT : Index No. ITEMIZED STATEMENT OF COMPENSATION : DWC No. Calendar No. Department of Labor and Training, Division of Workers' Compensation PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (401) 462-8006 : Insurer File No. JUDICIAL SUBPOENA Plaintiff(s) CLAIM INFORMATION: 2. 1. EMPLOYEE INFORMATION: -against- SSN : Employer Name Insurance Co. Address Claim Administrator City, State, Zip Injury date Date of death Defendant(s) : Incapacity date : Work-related OR Not : . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 . . . . . . . . . . . . at . . 3. . . . Incident. Only--No. payments. made..Complete.Section . .and return.to DLT only . .above address. All others continue below. 4. NONPAYMENT OF WEEKLY INDEMNITY ONLY: Check correct box and complete appropriate information on remainder of form. *Payment info must Medical Only* be listed below Federal Jurisdiction THE PEOPLE OF THE STATE OF NEW YORK Salary Continuation Death--Liability established; no dependents. Payment made to WCAF Denied Other: TO Do NOT use Other if claim is Denied 5. DIAGNOSIS: Primary Written Diagnosis ICD Code: Secondary Written Diagnosis ICD Code: GREETINGS: 6. PAYMENT INFORMATION: (List total amount paid for each appropriate item in both columns) DATE OF FIRST INDEMNITY PAYMENT: WE COMMAND YOU, that all business and Hospital/Treatmentlaid aside, you and each of you attend before excuses being Center , the Honorable at the Court Temporary Total Independent Medical Exams located at County of in room , on the day of , 20 Pharmaceutical o'clock in the , at noon, and at any recessed Permanent Total or adjourned date, to testify and give evidence as a witness in this action on the part of the Temporary Partial Weekly Death Benefits Chiropractic Burial Diagnostic Testing Attorney Fees Awarded by Court Specific - Disfigurement Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Penalties/Interest result of your failure to comply. Specific - Loss of Use Vocational Rehabilitation WC Administrative Fund (WCAF) Witness, Honorable Physical Therapy Settlement Court in Occupational Therapy County, day of , one of the Justices of the , 20 Deny & Dismiss Psychological Services Other Payments: Physicians Yes No Subrogation (Attorney must sign above and type name below) Did the employee return to employment? 7. RETURN TO EMPLOYMENT: If yes, was it with the same employer OR a 8. THIS REPORT WAS PREPARED BY: different employer Unknown Yes No Date Returned: Attorney(s) for Unknown Unknown PLEASE PRINT Name RI Adjuster License Number Company Name Office and P.O. Address Address City State Telephone Extension Signature Distribution: DWC-50 (01/03) Zip Code Email Telephone No.: Facsimile No.: E-Mail Address: Date DLT, Division of Workers' Compensation; Employee and Attorney; Employer Mobile Tel. No.: For instructions visit our web site: www.dlt.ri.gov/wc American LegalNet, Inc. www.USCourtForms.com