Report Of Indemnity Payment {DWC-22}

State of Rhode Island REPORT OF INDEMNITY PAYMENT Department of Labor and Training, Division of Workers' Compensation PO Box 20190, Cranston, RI 02920-0942 PLEASE CHECK IF CORRECTION OF PRIOR REPORT DWC No. Phone (401) 462-8100 TDD (401) 462-8006 YOU MUST CHECK ONE OF THE FOLLOWING: TERMINATION OF BENEFITS UNDER NON-PREJUDICIAL AGREEMENT* PAYMENT UNDER MEMO OF AGREEMENT, ORDER OR DECREE Insurer File No. YOU MUST CHECK ONE OF THE FOLLOWING: INTERIM FINAL: Date of last weekly indemnity payment: 1. EMPLOYEE INFORMATION: SSN Name Address City, State, Zip Phone Maximum no. of exemptions ________ Date of Birth Single Married 2. CLAIM INFORMATION: Employer Insurance Co. Claim Administrator Injury date Incapacity date Date of death AWW (include bonus/no OT) Total Cost of Living Adjustment(s) Weekly Dependency Rate Payment period Date through Number of Weeks & Days Total Weekly Rate Variable Partial Total Spendable Compensation Paid Settlement Deny&Dismiss Amount: NOT work-related 3. RATE INFORMATION: AWW including Overtime Spendable Base Wage Base Compensation Rate 4. WEEKLY COMPENSATION: Indicate Payment Type TI TI TI PI PI PI DB Decree No. Payment period Date from DB Decree Date DB Gross Earnings Spendable Earnings Amount Paid Week Ending Gross Earnings Spendable Earnings Amount Paid 5. WEEKLY COMPENSATION for Variable Partial Payments: (Complete information above also) Week Ending Signature: Print Name: RI Adjuster License Number: Date: Phone & Extension: *THE FOLLOWING NOTICE IS FOR EMPLOYEES TERMINATED UNDER A NON-PREJUDICIAL AGREEMENT ONLY Weekly compensation payments have stopped. The insurer/employer has not accepted liability for this claim. If you wish to protect any rights you may 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. DWC-22 (01/03) For instructions visit our web site: www.dlt.ri.gov/wc American LegalNet, Inc. www.FormsWorkFlow.com