Memorandum Of Agreement {DWC-02}

State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORTMEMORANDUM OF AGREEMEN T DWC No.PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (401) 462-8006 1.EMPLOYEE:2.EMPLOYER:SSNFEINNameNameAddressAddressAddressAddressCity, State, ZipCity, State, ZipPhoneDate of BirthPhoneExt.3.INSURANCE COMPANY NAMED ON WC POLICY:4.CLAIM ADMINISTRATOR:FEINFEINNameNameAddressAddressAddressAddressCity, State, ZipCity, State, ZipPhoneExt.PhoneExt.RI License NumberRI License or Self-Insurance NumberInjury date:List injured body parts and nature of injury:First date of first disability:Place where injury occurred:5.DISABILITY TYPE: (check all that apply) Death Benefits/Date of Death Temporary Total as of Payable to: Temporary Partial as of Permanent Total as of 6.RATE INFORMATION: Single Married Number of Exemptions AWW (include bonus/no OT) Average Overtime AmountAWW including Overtime Number of DependentsSpendable Base Wage Weekly Dependency RateBase Compensation Rate Total Weekly Rate7.DATE OF INITIAL PAYMENT UNDER MOA:Does employee have other employers?Yes No If yes, attach a wage statement from each employer.Is this a recurrence of a previous injury? Yes No Previous disability end date: Signature:Date:Print Name: RI Adjuster License Number: Phone & Extension: DWC-02 (0) For instructions visit our web site: www.dlt.ri.gov/w c ATTACH WAGE STATEMENT(S) AND DEPENDENCY FORMYOUMUSTREPORTANYEARNINGSyoureceivetotheClaimAdministratorthatpaysyourbenefits.Failuretoreportearningsmaysubjectyoutocivilorcriminalliability.Yourendorsementonabenefitcheckisyourstatementthatyouarequalifiedtoreceiveworkers'compensationbenefits.YouareNOTentitledtoreceiveworkers'compensationbenefitsforanytimethatyouareimprisonedas a result of a criminal conviction.Department of Labor and Training, Division of Workers' CompensationHas the employee worked at least 26 weeks prior to this recurrence? Yes No If yes, a new wage statement is required.Insurer File No.NOTICE TO EMPLOYEES RECEIVING WORKERS' COMPENSATION BENEFITS:SAME AS BLOCK 3 American LegalNet, Inc. www.FormsWorkFlow.com Memorandum of Agreement (DWC-02 0/20) Page 1 RIGL 247 28-35-1 requires the insurer to file a Memorandum of Agreement with The Department of Labor and Training (DLT) when indemnity benefits are paid voluntarily with liability. A Wage Statement (DWC-03) and Certificate of Dependency Status (DWC-04) must be submitted as part of the agreement. A copy of the agreement must also be sent to the employee and his or her attorney. As of March 1, 2015, the insurer must also submit an electronic Subsequent Report of Injury Initial Payment (SROI IP) to DLT when benefits begin. Instructions: Top of form: Correction Box: Check if this document is correcting a document previously filed.DWC No: For RI DLT use only. Please leave blank.Insurer File Number: Provide the claim number or file identification number for the company handlingthe claim: the insurer, self-insured employer or third party administrator.Employee information: 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: give the employee222s mailing address, city, state and zip.Phone: provide the employee222s telephone number if known.Date of birth: enter the employee222s date of birth.Employer information: Please provide the employer222s Federal Employer Identification Number, employer business name, employer business mailing address and phone number. Insurer information: Provide the information for the licensed insurer named on the workers222 compensation policy or the self-insured employer222s name. Include the Federal Employer Identification Number, insurer business name, insurer business address and phone number. Claim Administrator information: Supply information for the company handling the claim. Provide the claim administrator business name, mailing address, and phone number. If the claim administrator information is the same as the insurer, you may check the 223same as block 3224 box and leave block 4 blank. Injury Information: Injury Date: enter the date of the injury or start of illness.First date of first disability: give the first date of the waiting period.Place where injury occurred: enter the city and state where the injury occurred.List injured body part & nature of injury: list the nature of each injury and the employee222s injured bodyparts. Examples: cut right index finger, fractured right wrist or sprained lower back.Disability type: Check the box that corresponds with the type of disability being paid.Enter the start date for the type of disability paid. Include the waiting period.If death benefits are paid, include the date of death and the name of the primary survivor receivingdeath benefits. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Memorandum of Agreement (DWC-02 0/20) Rate Information: Employee222s marital status: check single if the employee is unmarried, divorced or widowed. Checkmarried if the employee is married or separated.Number of Exemptions: AWW (include bonus/no OT): enter the amount calculated from the wage statement for averageweekly wage with average bonus and without average overtime.Average Overtime Amount: enter the averaged amount of overtime from the wage statementAWW including Overtime: enter the total average weekly wage including bonus and overtime.Number of Dependents: enter the number of employee222s dependents including non-working spouseand dependent children. A child is dependent through age 18, or through age 23 if a full-time student.A disabled child is dependent at any age. See RIGL 247 28-35-1.Spendable Base Wage: calculate the Spendable Base Wage using the formulas or tables on the DLTweb site.Weekly Dependency Rate: Enter the total weekly amount of dependency allowance, up to 80% of totalAWW as allowed in RIGL 247 28-33-17 (c) (1). Dependency is $15 per dependent for temporary total and$40 per dependent for death benefits.Base Compensation Rate: Multiply the Spendable Base Wage by 75% to calculate the basecompensation rate. The rate can be no higher than the annual maximum compensation rate.Total Weekly Rate: Enter the total weekly compensation rate including dependency. Other Information: Date of initial payment under MOA: Enter the date of the first check made under this Memorandum ofAgreement.Does the employee have other employers? Check yes or no. A wage statement from each employer isneeded.Is this a recurrence of a previous injury? Check yes if this is a recurrence, meaning this is not the firstperiod of disability. Check no (not a recurrence) if this is the first period of disability.Previous disability end date: enter the last date of the previous disability to show if 26 weeks havepassed since the previous disability period ended.Has the employee worked at least 26 weeks before this recurrence? Check yes or no. If yes, a newwage statement must be completed based on this new disability date.Claim Adjuster Signature and Information Signature: The claim adjuster must sign this document.Date: Write the date the document was signed.Printed name: Print the claim adjuster222s name.Phone number: Provide the direct phone number for the claim adjuster. Send the document to the employee, the employee222s attorney, and the DLT within 10 days of the first payment issue date. Revised American LegalNet, Inc. www.FormsWorkFlow.com