State of Rhode Island Department of Labor and Training, Division of Workers Compensation PO Box 20190, Cranston, RI 02920-0942 (401) 462-8100 TDD (401) 462-8006 NOTICE TO EMPLOYEES REGARDING THE EFFECT OF EN DORSEMENT OF BENEFIT CHECK You are presently receiving or have filed a claim to receive workers compensation benefits. You should know and are hereby advised that by endorsing your workers compensation benefit check or upon deposit of your workers compensation check into an account, you are declaring that you are receiving benefits under the Workers Compensation Act. In other words, your endorsement on a weekly benefit check is your statement that you are entitled to receive workers compensation benefits for that week under the Workers Compensation Act and have made no false claims or statements or concealed any material fact. Furthermore, if you can return to any work and receive earnings, which includes wages, salary, commissions, bonuses, cash, and/or any other compensation other than money, YOU MUST REPORT THESE EARNINGS TO YOUR EMPLOYERS CLAIM ADMINISTRATOR IMMEDIATELY. If you endorse a benefit check that is for a week in which you had earnings AND YOU FAIL TO REPORT THESE EARNINGS, YOU MAY BE PROSECUTED BY THE ATTORNEY GENERAL AND SENT TO PRISON. You are NOT ENTITLED to receive workers compensation benefits for any time that you are imprisoned as a result of a criminal conviction. DWC-32 (01/03)