State of Rhode Island WAGE TRANSCRIPT Department of Labor and Training, Division of Workers' Compensation PLEASE CHECK IF CORRECTION OF PRIOR REPORT DWC No. Insurer File No. PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (401) 462-8006 This form will not be accepted for filing unless all information is completed. 1. EMPLOYEE INFORMATION: SSN Name Address City, State, Zip Phone 2. CLAIM INFORMATION: Employer Insurance Co. Claim Administrator Injury date Incapacity date 3. INSURER COMPLETE: This wage transcript is submitted to support a: Discontinuation of benefits. The employee has returned to work at a wage equal or greater than he or she earned at the time of the injury. Reduction of benefits. The employee has returned to work at a wage less than he or she earned at the time of the injury. Date benefits were discontinued or reduced: Pre-injury average weekly wage, not including overtime: 4. EMPLOYER COMPLETE: Post-Injury Earning Information -- WEEKS MUST BE CONSECUTIVE Period Start Date Period End Date Number of Hours Worked Payment Rate Amount of Earnings Week 1 Week 2 Employer Name: Address: City, State Zip: Phone: Employer Signature: Date: DWC-30 (01/03) For instructions visit our web site: www.dlt.ri.gov/wc American LegalNet, Inc. www.FormsWorkFlow.com