Form DWC-25 PDF Details

For individuals in Rhode Island receiving workers' compensation benefits, understanding the DWC-25 form, mandated by the Department of Labor and Training, Division of Workers' Compensation, is crucial. It serves as a comprehensive report of earnings during a specific period and ensures compliance with state workers' compensation rules. This document demands accurate representation of any income received outside of the workers’ compensation benefits, including but not limited to cash, wages, salary from self-employment, commissions, and bonuses, as well as the fair market value of non-cash compensation. It further elaborates on the importance of reporting unpaid work, symbolizing it with a hypothetical cost that such unpaid work would accrue if it were paid. The form is explicit in cautioning recipients about the obligations to report these earnings, framing the failure to do so as an act that may lead to criminal prosecution, civil liability, and potentially, the suspension or forfeiture of benefits. Additionally, it outlines the procedural steps for individuals who have or have not earned additional income during the coverage period, including the necessity of signing and returning the form to maintain the integrity of their workers’ compensation claims. This ensures both transparency and accountability, safeguarding the interests of the employee, the employer, and the insurer.

QuestionAnswer
Form Name Form DWC-25
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names forfeiture, Ext, gov, DWC-25, report of earinngs rhode island

Form Preview Example

STATE OF RHODE ISLAND

REPORT OF EARNINGS

Department of Labor and Training, Division of Workers' Compensation

Phone (401) 462-8100 TDD (401) 462-8006

 

 

Insurer File No.

 

1. EMPLOYEE INFORMATION:

2. CLAIM ADMINISTRATOR:

 

SSN

 

FEIN

 

 

Name

 

Name

 

 

Address

 

Address

 

 

City, State, Zip

 

City, State, Zip

 

 

Phone

 

Phone

 

Ext.

This report covers the time period from:

 

 

 

to:

PRESENT

3. NOTICE TO EMPLOYEES RECEIVING WORKERS' COMPENSATION:

If you are receiving weekly workers’ compensation benefits, YOU MUST REPORT ANY EARNINGS YOU RECEIVE TO THE CLAIM ADMINISTRATOR THAT IS PAYING YOUR BENEFITS. “Earnings” include any cash, wages, or salary received from self-employment or from any employer other than the employer where you were injured. Earnings also include commissions, bonuses, and the cash value for all payments received in any form other than cash (for example: a building custodian receiving a rent-free apartment).

Your endorsement on a benefit check or deposit of the check into an account is your statement that you are entitled to receive workers’ compensation benefits. Your signature on a benefit check is a further affirmation that you have made no false claims or statements or concealed any material fact regarding your workers’ compensation claim.

You must report any work for any business or person, even if the business or person lost money or if profits or income were reinvested or paid to others. If you performed any duties for any business or person for which you were not paid, you must show a rate of pay of what it would have cost the employer to hire someone to perform the work you did, even if your work was for yourself, a relative, or friend.

You are NOT entitled to workers’ compensation benefits for any time you are imprisoned as a result of a criminal conviction.

4. Employee Complete:

1. Did you receive earnings or payments during the above period?

State YES or NO:

2.Did you perform non-paid work activities during the above period? State YES or NO:

If you answered NO to BOTH questions, sign, date and return the form to the CLAIM ADMINISTRATOR above. If you answered YES to EITHER question, complete the following:

Employer Name

 

Self-Employed?

Yes

No

Address

 

Nature of business

 

 

City

State

Zip Code

Phone

 

5. Earnings Received:

Report pre-tax earnings. Include any cash, bonus, commission, and the cash value of any payment received in any form other than cash. Attach additional pages if necessary.

Date Earned:

Amount:

Date Earned:

Amount:

Date Earned:

Amount:

Date Earned:

Amount:

Failure to report earnings as defined will subject you to criminal prosecution and civil liability including the suspension or forfeiture of your benefits. This form MUST BE SIGNED, DATED and returned to the Claim Administrator -- EVEN IF YOU HAVE NO EARNINGS.

Employee Signature:

 

Date:

Witness Signature:

 

Date:

 

DWC-25 (01/03)

FOR INSTRUCTIONS VISIT OUR WEB SITE:

WWW.DLT.RI.GOV/WC

How to Edit Form DWC-25 Online for Free

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1. Fill out the reinvested with a selection of major fields. Note all of the required information and make sure nothing is forgotten!

Stage # 1 for completing wc

2. Just after the first part is done, go on to enter the relevant details in these - Employee Complete, Did you receive earnings or, Did you perform nonpaid work, If you answered NO to BOTH, If you answered YES to EITHER, Employer Name, Address, City, SelfEmployed, Yes, Nature of business, State, Zip Code, Phone, and Earnings Received.

Guidelines on how to fill in wc stage 2

3. This subsequent part is considered fairly simple, Employee Signature, Witness Signature, DWC, For instructions visit our web, Date, and Date - each one of these blanks needs to be filled in here.

Completing section 3 in wc

A lot of people often get some points wrong when filling in Employee Signature in this section. You should double-check everything you enter right here.

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