State of Rhode Island COORDINATION OF RETIREMENT BENEFITS Department of Labor and Training, Division of Workers' Compensation PO Box 20190, Cranston, RI 02920-0942 Claim Administrator Complete 1-6 PLEASE CHECK IF CORRECTION OF PRIOR REPORT DWC No. Insurer File No. 2. EMPLOYER: FEIN Name Address City, State, Zip Phone Phone (401) 462-8100 TDD (401) 462-8006 1. EMPLOYEE: SSN Name Address City, State, Zip Phone FEIN Name Address City, State, Zip Phone Date of Birth Ext. 3. INSURANCE COMPANY NAMED ON WC POLICY: 4. CLAIM ADMINISTRATOR: FEIN Name Address City, State, Zip Phone SAME AS BLOCK 3 Ext. Age at the time of injury: Ext. Incapacity date: 5. INJURY INFORMATION: Injury date: 6. RATE INFORMATION: Weekly workers' compensation indemnity amount: Employee/Employer Complete: 7. RETIREMENT INFORMATION: Retirement Date: Total amount of employee contribution: Weekly retirement amount: Please verify that the information above is correct. Complete this section, with signatures, and return entire form to claim administrator listed in Section 4 above. Retirement Benefits Paid By: Company Name: Address: City: State: Zip: Phone: The information listed in Section 7 for the named employee is a true and accurate statement of retirement benefits to the best of my knowledge and ability. Employer Signature: Employee Signature: Date: Date: Claim Administrator completes appropriate Section(s) below after completion of Section 7 by Employee/Employer The offset provided for pursuant to RIGL §28-33-45 shall not be applicable to those collecting retirement benefits while collecting compensation benefits for an injury sustained before the age of fifty-five (55) years and more than five (5) years prior to the date of retirement. An employee shall not collect any indemnity benefits after his or her retirement for any injury sustained less than two (2) years prior to his or her retirement. 8. Based on the above, this employee is not eligible for continued workers' compensation benefits. 9. EMPLOYEE DID CONTRIBUTE TO RETIREMENT: Total amount of employee contribution: Weekly retirement amount: Divide contribution by weekly retirement amount*: Check if appropriate 10. EMPLOYEE DID NOT CONTRIBUTE OR OFFSET CALCULATION AFTER EMPLOYEE CONTRIBUTION: Weekly workers' compensation amount: Weekly retirement amount: Subtract retirement from workers' compensation*: *Dividing the employee contribution amount by the weekly retirement amount will result in the number of weeks without any offset or reduction to the workers' compensation weekly indemnity amount. At no time is the retirement amount altered. *If the retirement amount is greater, the employee receives no workers' compensation monies. If the workers' compensation amount is greater, the employee receives the difference as their workers' compensation amount. At no time is the retirement amount altered. Print Adjuster Name: Date: A copy of this completed form shall be forwarded by the claim administrator to the RI Department of Labor and Training, Division of Workers' Compensation, the employer, and the employee and his or her attorney within ten (10) working days of the receipt of the form. Either party has a right to a review of any decision regarding coordination of benefits by the Workers' Compensation Court, pursuant to RIGL §28-35-11. DWC-36 (04/05) American LegalNet, Inc. www.FormsWorkFlow.com