Employees Certificate Of Dependency Status {DWC-04}

Check if this is a corrected report DWC-04 (/1) DateEmployee's SignatureYesNoNoYesYesYesNoNoSSN: XXX - XX -Employee: complete this form and return it to the Claim Administrator. This information is needed to calculate your compensation rate.PhoneDate of BirthNo3.Marital StatusCity, St, ZipMarriedSpouse's nameSpouse does not workSpouse works5.DependentsA dependent for workers' compensation includes children you support who are:AddressAddressCity, St, ZipUnder age 18, or age 18 to 23 and a full time student 4.Number of Exemptions Enter the maximum number of xemptions you are allowed to claim for . Include yourself, your spouse, your dependents, and any other exemptions. NameClaim AdministratorMentally or physically incapacitated from earning at any ageYesDate of BirthEmployee's Certificate of Dependency StatusNoState of Rhode IslandEmployer name1.Employee information:2.Claim information:NoNoNoYesYesYesAt the time of the injury the employee was SingleRelationshipInjury DateIncapacity DateDependent's NameFull time student?YesDepartment of Labor and Training, Division of Workers' CompensationPO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 Claim Administrator File Number: American LegalNet, Inc. www.FormsWorkFlow.com Employee222s Certificate of Dependency Status (DWC-04 /201) Page 1 An Employee222s Certificate of Dependency Status is required with a Memorandum of Agreement or a Nonprejudicial Agreement to verify marital status, maximum number of exemptions, and number of dependents for calculation of weekly benefits. The claim administrator (the company handling the claim: the insurer, self-insured employer or third party administrator) completes sections 1 and 2 of the form. The employee completes the rest of the form, signs it, and returns the form to the claim administrator. The claim administrator sends the form to the DLT as part of a Nonprejudicial Agreement, Memorandum of Agreement, or as required by court order or decree. Top of form: Correction Box: Check if this document is correcting a document previously filed.Claim Administrator File Number: Provide the claim number or file identification number for thecompany handling the claim: the insurer, self-insured employer or third party administrator. Employee Information. The claim administrator completes section 1.SSN: provide at least the last 4 digits of the employee222s social security number or the employee IDnumber assigned by RIDLT. DO NOT USE A FICTITIOUS NUMBER. Please contact RI DLT to obtain anassigned employee ID number.Name: enter the employee222s first name, middle initial and last name.Address: complete the employee222s street address, city, state, and zip code.Phone: provide the employee222s phone number if available.Date of Birth: enter the employee222s date of birth if available.Claim Information. The claim administrator completes section 2.Employer name: enter the company name of the injured worker222s employer.Claim Administrator: enter the company name of the party handling the claim.Address: complete the mailing address for the claim administrator.Injury date: enter the injury date.Incapacity date: Enter the incapacity date, which is the first full day that the employee was unableto work.Marital Status. The employee completes section 3.Check the single box if you are unmarried, widowed or divorced. Check the married box if you aremarried or separated.If you are single, leave the rest of section 3 blank.Check 223Spouse works224 if your spouse is employed or 223Spouse does not work224 if not. A non-workingspouse qualifies as a dependent for workers222 compensation.Enter your spouse222s name.Number of Exemptions. The employee completes section 4.Enter the maximum number of exemptions you are allowed to claim for . Thisincludes you, your spouse, your dependent children, and any otherexemptions. American LegalNet, Inc. www.FormsWorkFlow.com Employee222s Certificate of Dependency Status (DWC-04 /201) Page 2 Dependents. The employee completes section 5. The employee must sign and date the form and return the form to the claim administrator. The claim administrator sends the form to the Department of Labor and Training as part of a Nonprejudicial Agreement, Memorandum of Agreement, or as required by court order or decree. Revised American LegalNet, Inc. www.FormsWorkFlow.com