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 Employee Information SSN or ID Last Name Date of Injury Date of Birth First Name Date of Death Initial Claim Administrator Claim Number Employer, Insurer & Claim Administrator Employer Business Name Insurer Business Name Claim Administrator Business Name 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 Change the total average weekly wage to Change the weekly spendable base wage to Change the weekly compensation rate to Change maximum number of eligible exemptions Change number of dependents Modify from total to partial incapacity Modify from partial to total incapacity Suitable Alternative Employment (offer attached) Change nature of injury and/or affected body part to Other (specify) Married $ $ $ to to effective date: effective date: effective date: effective date: effective date: effective date: effective date: effective date: effective date: Specific Injury Agreement The injured worker and the Claims Administrator representing the Insurer and Employer agree on the specific injury or injuries stated here. Weeks Weekly Rate Amount Paid Date Paid Disfigurement: Body Part Loss of Use: Body Part Percent Weeks Weekly Rate Amount Paid Date Paid Body Part Type of Hearing Loss Left Occupational Right Occupational Both Occupational Percent Weeks Weekly Rate Amount Paid Date Paid Traumatic Traumatic Traumatic Signatures of Parties to this Agreement Employee Signature Date Claim Adjuster Signature Date DWC-24 1/2014 American LegalNet, Inc. www.FormsWorkFlow.com