Get Completed By Insurer And Employee - Dlt Ri

Filling out the Completed By Insurer And Employee - Dlt Ri form is an essential step in managing workers’ compensation claims. This guide provides clear, step-by-step instructions to help both insurers and employees complete the form accurately and efficiently.

Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to access the form and open it in your preferred online document editor.
2. Begin with the Employee Information section. Enter the employee's Social Security Number, full name, current mailing address (including city, state, and zip), and home telephone number.
3. Proceed to the Claim Information section. Fill in the employer's actual name, the name of the worker’s compensation insurer, or note ‘Self-Insured’ if applicable. Also, provide the name of the claim administrator, the date of the injury, and the date of incapacity.
4. In the Insurer Complete section, indicate whether there was a discontinuation or reduction of benefits by checking the appropriate box. Record the date when benefits were discontinued or reduced and enter the employee's pre-injury average weekly wage, excluding overtime.
5. Next, complete the Employer Complete section. Enter the post-injury earning information, including the starting and ending dates for the earnings period, the number of hours worked, the payment rate, and the total amount of earnings for that period.
6. Input the employer's name, mailing address (including city, state, and zip), and phone number. Obtain the signature of the employer’s Treasurer or another authorized official along with the date the form was prepared.
7. Once all sections are completed, review the form for accuracy. Save your changes, and choose to download or print the form for distribution.

Complete your documents online today for a seamless experience!