COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : General Instructions: Index No. REPORT OF INDEMNITY PAYMENT : Calendar No. (DWC-22) : JUDICIAL Plaintiff(s) -againstCompleted by: Claim Administrator. SUBPOENA : Time Frame: As a Termination of Benefits under Non-Prejudicial Agreement: Within ten days of the termination of benefits. As a : payment under Memorandum of Agreement (MOA): Initial report should be attached to MOA. Additional reports are due every six months on an ongoing claim or any time there is any change in the compensation rate (i.e. COLA or change in dependents). : Distribution: Original to Department of Labor and Training. When used as a Termination of Benefits under Non-Prejudicial Agreement, copies must be sent to employee and his or her attorney within ten days of the termination of payments. Defendant(s) : . . . . . Attachments:. . .When .submitting .a. final. . . . . . . report. under. an. MOA, .a .Suspension ....... . . . . . . . . . . . payment . . . . . . . . . . . . . Agreement and Receipt (DWC-5) should be attached. Definitions: PLEASE CHECK IF CORRECTION OF PRIOR REPORT: Check if sending in an amended form. THE PEOPLE OF THE ONE OF THE FOLLOWING: YOU MUST CHECK STATE OF NEW YORK • Termination of Benefits Under Non-Prejudicial Agreement: Check only when ending benefits under a Non-Prejudicial Agreement. • Payment under Memo of Agreement, Order or Decree: Check when appropriate. TO YOU MUST CHECK ONE OF THE FOLLOWING: • Report type: Final or Interim: Check Interim when weekly indemnity payments will continue. Check Final when weekly indemnity payments have ended. Termination of Benefits will always be a Final. • If final, date of last weekly indemnity payment: Enter the date of the last weekly indemnity check. 1. Employee Information: GREETINGS: SSN: Employee’s Social Security Number. Name: Employee’s full name. Address (including city, state, zip): Employee’s current mailing address. WE Employee’s current home telephone number. Phone: COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before the HonorableBirth: Date the employee was born. at the Court Date of 2. Claim Information: located at County of Employer: Employer’s actual name where the employee was employed at the time of the injury. in room Insurance Co.:, Name of the worker’s compensation insurer, OR ‘Self-Insured’ if the company has been certifiednoon, and at any recessed on the day of 20 , at o'clock in the as self-insured by DLT. Claim date, to testify and give insurance carrier, witness in this action on the employer responsible for or adjourned Administrator: Name of the WCevidence as a third party administrator, or self-insuredpart of the 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 box if death was NOT work-related. 3. Rate Information: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to AWW including Overtime: Enter appropriate figure as listed on Agreement, Order or Decree. the party on whose behalf this subpoena waslisted on Agreement. Spendable Base Wage: Enter appropriate figure as issued for a maximum penalty of $50 and all damages sustained as a result ofBase Compensation Rate: Enter appropriate figure as listed on Agreement. your failure to comply. AWW (include bonus/no OT): Enter appropriate figure as listed on Agreement. Total Cost of Living Adjustment(s): If claimant is entitled, enter total cumulative amount calculated for Cost of Living Adjustment. Weekly Dependency Rate: Total Incapacity Only. $15 per dependent or $40 per dependent for death claim. Justices of the Witness, Honorable , one of the 4. Weekly Compensation: Court inIndicate Payment Type: County, day of , 20 • TI: Total Incapacity • PI: Partial Incapacity • DB: Death Benefits Payment period Date from: Date of Incapacity (first full day without wages). Do not adjust date for three-day waiting period. (Attorney must Payment period Date through: Last date of the benefit period for which benefits were paid. sign above and type name below) Number of Weeks & Days: Number of weeks and days that the payment represents. Three-day waiting period may be deducted here. Total Weekly Rate: Total weekly compensation rate used. Variable Partial Total Spendable: Only use when paying ‘variable’ or ‘working’ partial. Total amount of Spendable Earnings for the weeks of variable partial as listed in Section 5 of this form. See Calculation of a Variable Partial for more information. Attorney(s) for Compensation Paid: Total compensation paid. Settlement/Deny & Dismiss: Enter amount of settlement or D&D, WC Court Decree number, and date of Decree. 5. Weekly Compensation for Variable Partial Payments: Week Ending: Week ending date for the Gross Earnings listed. Gross Earnings: Total weekly gross earnings of claimant. Spendable Base Wage: Enter appropriate figure from Gross Wage to Spendable Earnings Table. Note: If paying Suitable Alternative Office and P.O. noted. Employment (SAE) write ‘SAE’ in the Spendable Earnings column and complete other columns as Address Amount Paid: Amount paid by the claim administrator for that week. Signature/Date: Signature of the person who filled out the form and the date that the form was prepared. Print Name/RI Adjuster License Number/Phone & Extension: Clearly enter the name of the No.: who filled out the form, their RI Telephone person Adjuster License Number as issued by the RI Department of Business Regulation, and the complete phone number of the preparer. Facsimile No.: Note: DO NOT ENTER SSN – Request another number from DBR. E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com , COURT State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . OF .INDEMNITY .PAYMENT . . . . . . . . . . . . . . . . . . . . . . . ... .. REPORT : Index Department of Labor and Training, Division of Workers' Compensation DWC No.No. PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (401) 462-8006 : Calendar No. Insurer File No. YOU MUST CHECK ONE OF THE FOLLOWING: YOU MUST: CHECK ONE OF THE FOLLOWING: JUDICIAL SUBPOENA Plaintiff(s) TERMINATION OF BENEFITS UNDER NON-PREJUDICIAL AGREEMENT* INTERIM PAYMENT UNDER MEMO OF AGREEMENT, ORDER OR DECREE FINAL: Date of last weekly indemnity payment: -against: 1. EMPLOYEE INFORMATION: 2. CLAIM INFORMATION: : SSN Employer Name Insurance Co. : Address Claim Administrator Defendant(s) : City, State, Zip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Injury date . . . ..... ....... Phone Maximum no. of exemptions ________ Date of Birth Single Married Incapacity date NOT work-related Date of death 3. RATE INFORMATION: THE STATE OF NEW YORK THE PEOPLE OF AWW including Overtime TO Spendable Base Wage Base Compensation Rate AWW (include bonus/no OT) Total Cost of Living Adjustment(s) Weekly Dependency Rate 4. WEEKLY COMPENSATION: Indicate Payment period GREETINGS: Payment Type Date from Payment period Date through Number of Weeks & Days Total Weekly Rate Variable Partial Total Spendable Compensation Paid Settlement Deny&Dismiss Amount: TI PI DB WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , at the Court Decree No. located at Decree Date in room , on the day of , 20 , at o'clock in the noon, and at any recessed TI or adjourned date, to testify and give evidence as a witness in this action on the part of the PI DB 5. WEEKLY COMPENSATION for Variable Partial Payments: (Complete information above also) the Honorable TI County of PI DB Week Ending Gross Earnings Spendable Earnings Amount Paid Week Ending Gross Earnings Spendable Earnings Amount Paid 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 result of your failure to comply. Court in Witness, Honorable County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Signature: Date: Office and P.O. Address Print Name: RI Adjuster License Number: Phone & Extension: Telephone No.: Facsimile No.: Weekly compensation payments have stopped. The insurer/employer has not accepted liability for this claim. If you wish to protect any rights you may E-Mail Address: have under the Workers' Compensation Act, including possible entitlement to continued or future weekly compensation payments or payment of medical expenses, a petition must be filed with the Workers' Compensation Court within two (2) years from the first date of incapacity. Mobile Tel. No.: *THE FOLLOWING NOTICE IS FOR EMPLOYEES TERMINATED UNDER A NON-PREJUDICIAL AGREEMENT ONLY DWC-22 (01/03) For instructions visit our web site: www.dlt.ri.gov/wc American LegalNet, Inc. www.USCourtForms.com