COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : General Instructions: Index No. REPORT OF SPECIFIC PAYMENT : Calendar No. (DWC-51) : JUDICIAL Plaintiff(s) -againstCompleted by: Claim Administrator SUBPOENA : Time Frame: The Report of Specific Payment should be filed with the Department of Labor and Training (DLT) within 10 days of : payment. Payment must be mailed to claimant within 14 days of the entry of a decree, order, or agreement of the parties. Distribution: Original to DLT. Attachments: None. : Defendant(s) : . .Definitions:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......... PLEASE CHECK IF CORRECTION OF PRIOR REPORT: Check if sending in an amended form. YOU MUST CHECK ONE OF THE FOLLOWING: • Lost Time: Check if claimant received any weekly indemnity payments. • No THE PEOPLE Lost Time: Check if claimant did not receive any weekly indemnity payments. OF THE STATE OF NEW YORK • Federal Jurisdiction: Check if claim was paid under Federal jurisdiction. 1. Employee: SSN: Employee’s Social Security Number. TO Name: Employee’s full name. Address (including city, state, zip): Employee’s current mailing address. Phone: Employee’s current home telephone number. Date of Birth: Date the employee was born. 2. Employer: GREETINGS: FEIN: Employer’s Federal Employer Identification Number. Name: Employer’s actual name where the employee was employed at the time of the injury. Address (including city, state, zip): Address of the employer’s actual location. WE COMMAND and extension all business and excuses being Phone/Ext: Phone number YOU, that (if necessary) of the employer’s facility. laid aside, you and each of you attend before 3. Insurance company named on WC Policy: the Honorable at the Court FEIN: WC Insurance company’s Federal Employer Identification Number. located at OR ‘Self-Insured’ if the company has been certified as self-insured by DLT. County of Name: Name of the worker’s compensation insurer in room Address (including city, state, zip): Mailing address of the WC insuranceat , on the day of , 20 , carrier named on the WC Insurance Policy. and at any recessed o'clock in the noon, Phone/Ext: Phone number and give evidence as a witness in insurance carrier. or adjourned date, to testify and extension (if necessary) of the named WC this action on the part of the RI License Number: License number issued by the RI Department of Business Regulation (DBR). 4. Claim Administrator: If this information is identical to the information in Block 3, check the ‘Same’ box. If different, proceed below. FEIN: Federal Employer Identification Number of the company administering the claim. Name: Name of the WC insurance carrier, third party administrator, or self-insured employer responsible for administering the claim. Address (including city, state, zip): Mailing address of the claim administrator. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Phone/Ext: Phone number and extension (if necessary) of the claim administrator. the party on whose behalf this subpoena was issued forDBR or Self-Insurance Certificate$50 and allby DLT. RI License or Self-Insurance Number: License number issued by a maximum penalty of number issued damages sustained as a 5. Claim Information: result of your failure to comply. Injury date: Date that the accident happened. Incapacity Date(if appropriate): First full day that the employee lost from work (include weekends and holidays). Average Weekly Wage (including OT): Claimant’s total average weekly wage. Witness, Honorable , one of the Justices of the Weekly Specific Rate: Weekly rate used to pay specific. Court inSpecific paid by: County, day of , 20 • Pretrial Order or Decree/Date/Number: Check appropriate box and enter date and Court-assigned number of document. • Agreement of the Parties: Check if appropriate. • Description of Injury/Specific: Describe what the specific payment is being made for. 6. Specific Payment Information: (Attorney must sign above and type name below) Indicate Payment Type/disfigurement or loss of use: Check appropriate box(es). Body Part: Enter appropriate part of body. Percent of Loss: Enter percentage of loss. Number of Weeks: Enter number of weeks being paid for that entry. Amount Paid: Total amount paid for that entry. Attorney(s) for Date Paid: Enter payment date for that entry. Hearing Loss/ Left/Right Ear-Occupational/Traumatic: Check appropriate box(es). Total/Partial Deafness: Check appropriate box(es). Number of Weeks: Enter number of weeks being paid for that entry. Amount Paid: Total amount paid for that entry. Office Date Paid: Enter payment date for that entry. and P.O. Address Employee Signature (optional)/Date: If the Report has been paid by Agreement of Parties, this allows the option for the claimant to sign and date. Employer/Insurer Signature/Date: Signature of employer or insurer and dateTelephone No.: prepared. Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. State of Rhode Island PLEASE CHECK IF No. : Index CORRECTION OF PRIOR REPORT REPORT OF SPECIFIC PAYMENT : DWC No. No. Department of Labor and Training, Division of Workers' Compensation Calendar PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (401) 462-8084 : Plaintiff(s) YOU MUST CHECK ONE OF THE-againstFOLLOWING: LOST TIME Insurer File No. SUBPOENA JUDICIAL : NO LOST TIME FEDERAL JURISDICTION : 1. EMPLOYEE: 2. EMPLOYER: : SSN FEIN Name Name Defendant(s) : Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address. . . . . . ..... Address Address City, State, Zip City, State, Zip Phone Date of Birth Phone Ext. THE PEOPLE OF THE STATE POLICY: 3. INSURANCE COMPANY NAMED ON WCOF NEW YORK 4. CLAIM ADMINISTRATOR: FEIN Name TO Address Address City, State, Zip Phone GREETINGS: RI License Number FEIN Name Address Address City, State, Zip Phone RI License or Self-Insurance Number Ext. SAME AS BLOCK 3 Ext. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 5. CLAIM INFORMATION: , at the Court Incapacity date (if appropriate) located at in room , OT) day of , 20Weekly at , Specific Rate o'clock in the noon, and at any recessed Average Weekly Wage (includingon the or adjourned date, to testify and give evidence as a witness in this action on the part of the the Honorable Injury date County of Specific paid by: Court Order Date: OR Number: Agreement of the Parties Description of Injury/Specific: 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 Attorney Fee: result of your failure to comply. 6. SPECIFIC PAYMENT INFORMATION: Witness, Honorable Court in County, Indicate Payment Type disfigurement day of , 20 loss of use disfigurement Percent of Loss Number of Weeks Amount Paid Date Paid loss of use disfigurement , one of the Justices of the Body Part loss of use (Attorney must sign above and type name below) Hearing Loss Total/Partial Deafness Left Ear occupational traumatic total Right Ear occupational traumatic total Employee Signature: (Not required for Court Order) DWC-51 (01/03) Date: Attorney(s) for Number of Weeks Amount Paid Date Paid partial Office and P.O. Address partial Employer/Insurer Signature: Telephone No.: For instructions visit our web site: Date: Facsimile No.: E-Mail Address: Mobile Tel. No.: www.dlt.state.ri.us/wc American LegalNet, Inc. www.USCourtForms.com