Form DWC-25 at a glance
What it is: Report of Earnings, DWC-25 (Rev. 01/2021), State of Rhode Island, Department of Labor and Training, Division of Workers' Compensation.
Where and when to file: Return the form to the CLAIM ADMINISTRATOR, not to the Department of Labor & Training. DWC-25 (Rev. 01/2021), page 1: the claim administrator (the company handling the claim: the insurer, self-insured employer or third party administrator) sends the form to the employee to complete at the beginning of a claim, at reasonable intervals throughout the claim, and at the end of a claim.
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).
A filled-in Form DWC-25 example: an employee reports one part-time payment
How to fill out Form DWC-25, box by box
Insurer File No.
Insurer File Number: Provide the claim number or file identification number for the company handling the claim: the insurer, self-insured employer or third party administrator.
Employee Information
Employee Information. The claim administrator completes section 1. SSN: enter at most the last 4 digits of the employee's social security number or the employee ID number assigned by DLT.
DO NOT use a fictitious number. Name: enter the employee's first name, middle initial and last name. Address: complete the employee's street address, city, state and zip code. Provide the employee's phone number if available.
Claim Administrator
The claim administrator completes section 2. Complete the information for the company handling the claim. Provide the claim administrator business name, mailing address, and phone number.
From date
From date: enter the first day the employee lost time from work due to the injury (incapacity date).
Employee Complete
Employee Complete: Read the questions and WRITE IN either YES or NO. If you answered NO to BOTH questions, sign and date the form.
1. Did you receive earnings or payments during the time period this report covers? State YES or NO. 2. Did you perform non-paid work activities during the time period this report covers? State YES or NO.
Employer Name
If you answered YES to either question, complete the employer and earnings information. Employer information: give the business name and address of the employer that provided the earnings. Return the completed form to the claim administrator (not to RI Department of Labor and Training).
Employer Name Self-Employed? Yes No. Address Nature of business. City State Zip Code Phone.
Earnings Received
The employee reports earnings received: give the date of earnings and amount 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.
Attach another page if needed.
More rules for Form DWC-25
This form MUST BE SIGNED, DATED and returned to the Claim Administrator, EVEN IF YOU HAVE NO EARNINGS.
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.
RIDLT accepts any digital signature solutions that conform to current standards for integrity and authenticity. However, typed names in lieu of signatures do not meet this standard and will not be accepted.
You are NOT entitled to workers' compensation benefits for any time you are imprisoned as a result of a criminal conviction.
If your situation is different
You performed duties for which you were not paid
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.
Common questions about Form DWC-25
What does DWC 25 stand for?
Report of Earnings, DWC-25 (Rev. 01/2021), State of Rhode Island, Department of Labor and Training, Division of Workers' Compensation. The employee completes the form and returns it to the claim administrator.
Who signs it?
Signature: The employee must sign and date the form. A witness to the employee's signature must sign and date the form.
Where do I file it?
Return the form to the CLAIM ADMINISTRATOR, not to the Department of Labor & Training.
Is there a penalty?
Failure to report earnings as defined will subject you to criminal prosecution and civil liability including the suspension or forfeiture of your benefits.
Sources
[1] Form DWC-25 (Rev. 01/2021), Report of Earnings, Rhode Island Department of Labor and Training (the Official source link on this page).