Form DWC-36 "Coordination of Retirement Benefits" - Rhode Island

What Is Form DWC-36?

This is a legal form that was released by the Rhode Island Department of Labor and Training - a government authority operating within Rhode Island. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2021;
  • The latest edition provided by the Rhode Island Department of Labor and Training;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DWC-36 by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Labor and Training.

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Download Form DWC-36 "Coordination of Retirement Benefits" - Rhode Island

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State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
COORDINATION OF RETIREMENT BENEFITS
DWC No.
Department of Labor and Training, Division of Workers' Compensation
PO Box 20190, Cranston, RI 02920-0942 Phone: (401) 462-8100 TTY (Relay RI): 711
Insurer File No.
Claim Administrator Complete 1-6
1. EMPLOYEE:
2. EMPLOYER:
SSN or ID
XXX-XX-
FEIN
Last four digits only
Name
Name
Address
Address
City, State, Zip
City, State, Zip
Phone
Date of Birth
Phone
Ext.
3. INSURANCE COMPANY NAMED ON WC POLICY:
4. CLAIM ADMINISTRATOR:
SAME AS BLOCK 3
FEIN
FEIN
Name
Name
Address
Address
City, State, Zip
City, State, Zip
Phone
Ext.
Phone
Ext.
5. INJURY INFORMATION:
Injury date:
Age at the time of injury:
Incapacity date:
6. RATE INFORMATION:
Weekly workers' compensation indemnity amount:
Please verify that the information above is correct. Complete this section, with signatures, and return entire
Employee/Employer Complete:
form to claim administrator listed in Section 4 above.
Retirement Benefits Paid By:
7. RETIREMENT INFORMATION:
Retirement Date:
Company Name:
Phone:
Total amount of employee contribution:
Address:
Weekly retirement amount:
City:
State:
Zip:
The information listed in Section 7 for the named employee is a true and accurate statement of retirement benefits to the best of my knowledge and ability.
Employer Signature:
Date:
Employee Signature:
Date:
Claim Administrator completes appropriate Section(s) below after completion of Section 7 by Employee/Employer
The offset provided for pursuant to RIGL §28-33-45 shall not be applicable to those collecting retirement benefits while collecting compensation benefits for
an injury sustained before the age of fifty-five (55) years and more than five (5) years prior to the date of retirement. An employee shall not collect any
indemnity benefits after his or her retirement for any injury sustained less than two (2) years prior to his or her retirement.
8. Based on the above, this employee is not eligible for continued workers' compensation benefits.
Check if appropriate
9. EMPLOYEE DID CONTRIBUTE TO RETIREMENT:
10. EMPLOYEE DID NOT CONTRIBUTE OR OFFSET
CALCULATION AFTER EMPLOYEE CONTRIBUTION:
Total amount of employee contribution:
Weekly workers' compensation amount:
Weekly retirement amount:
Weekly retirement amount:
Divide contribution by weekly retirement amount*:
Subtract retirement from workers' compensation*:
*Dividing the employee contribution amount by the weekly retirement amount
*If the retirement amount is greater, the employee receives no workers'
will result in the number of weeks without any offset or reduction to the
compensation monies. If the workers' compensation amount is greater, the
workers' compensation weekly indemnity amount. At no time is the
employee receives the difference as their workers' compensation amount. At
retirement amount altered.
no time is the retirement amount altered.
Print Adjuster Name:
Date:
A copy of this completed form shall be forwarded by the claim administrator to the RI Department of Labor and Training, Division of Workers’ Compensation,
the employer, and the employee and his or her attorney within ten (10) working days of the receipt of the form. Either party has a right to a review of any
decision regarding coordination of benefits by the Workers' Compensation Court, pursuant to RIGL §28-35-11.
DWC-36 (Rev. 01/2021)
State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
COORDINATION OF RETIREMENT BENEFITS
DWC No.
Department of Labor and Training, Division of Workers' Compensation
PO Box 20190, Cranston, RI 02920-0942 Phone: (401) 462-8100 TTY (Relay RI): 711
Insurer File No.
Claim Administrator Complete 1-6
1. EMPLOYEE:
2. EMPLOYER:
SSN or ID
XXX-XX-
FEIN
Last four digits only
Name
Name
Address
Address
City, State, Zip
City, State, Zip
Phone
Date of Birth
Phone
Ext.
3. INSURANCE COMPANY NAMED ON WC POLICY:
4. CLAIM ADMINISTRATOR:
SAME AS BLOCK 3
FEIN
FEIN
Name
Name
Address
Address
City, State, Zip
City, State, Zip
Phone
Ext.
Phone
Ext.
5. INJURY INFORMATION:
Injury date:
Age at the time of injury:
Incapacity date:
6. RATE INFORMATION:
Weekly workers' compensation indemnity amount:
Please verify that the information above is correct. Complete this section, with signatures, and return entire
Employee/Employer Complete:
form to claim administrator listed in Section 4 above.
Retirement Benefits Paid By:
7. RETIREMENT INFORMATION:
Retirement Date:
Company Name:
Phone:
Total amount of employee contribution:
Address:
Weekly retirement amount:
City:
State:
Zip:
The information listed in Section 7 for the named employee is a true and accurate statement of retirement benefits to the best of my knowledge and ability.
Employer Signature:
Date:
Employee Signature:
Date:
Claim Administrator completes appropriate Section(s) below after completion of Section 7 by Employee/Employer
The offset provided for pursuant to RIGL §28-33-45 shall not be applicable to those collecting retirement benefits while collecting compensation benefits for
an injury sustained before the age of fifty-five (55) years and more than five (5) years prior to the date of retirement. An employee shall not collect any
indemnity benefits after his or her retirement for any injury sustained less than two (2) years prior to his or her retirement.
8. Based on the above, this employee is not eligible for continued workers' compensation benefits.
Check if appropriate
9. EMPLOYEE DID CONTRIBUTE TO RETIREMENT:
10. EMPLOYEE DID NOT CONTRIBUTE OR OFFSET
CALCULATION AFTER EMPLOYEE CONTRIBUTION:
Total amount of employee contribution:
Weekly workers' compensation amount:
Weekly retirement amount:
Weekly retirement amount:
Divide contribution by weekly retirement amount*:
Subtract retirement from workers' compensation*:
*Dividing the employee contribution amount by the weekly retirement amount
*If the retirement amount is greater, the employee receives no workers'
will result in the number of weeks without any offset or reduction to the
compensation monies. If the workers' compensation amount is greater, the
workers' compensation weekly indemnity amount. At no time is the
employee receives the difference as their workers' compensation amount. At
retirement amount altered.
no time is the retirement amount altered.
Print Adjuster Name:
Date:
A copy of this completed form shall be forwarded by the claim administrator to the RI Department of Labor and Training, Division of Workers’ Compensation,
the employer, and the employee and his or her attorney within ten (10) working days of the receipt of the form. Either party has a right to a review of any
decision regarding coordination of benefits by the Workers' Compensation Court, pursuant to RIGL §28-35-11.
DWC-36 (Rev. 01/2021)
RULES AND REGULATIONS FOR COORDINATION OF BENEFITS
Pursuant to RIGL §28-33-45
1.
The employer, upon notice of retirement by an employee being compensated under the
Workers’ Compensation Act for an injury, shall notify their workers’ compensation claim
administrator of employee’s intent to retire.
2.
Upon receipt of notice from the employer, the claim administrator shall complete the
appropriate information in Sections 1 through 6 on the RI Department of Labor and
Training form DWC-36 entitled, Coordination of Retirement Benefits.
The claim
administrator shall send the form, with the appropriate Sections completed, to the
employer within ten (10) days of the notice of retirement.
3.
The employer, with the assistance of the employee if necessary, completes Section 7,
relating to retirement information.
4.
Upon completion of Section 7, the form shall be signed by the employer (or his or her
designee) and by the employee attesting that the information requested has been supplied
and is correct to the best of their knowledge.
5.
The employer or employee shall send the original completed form (DWC-36) back to the
claim administrator within twenty-one (21) calendar days from the date of original
receipt.
6.
If the employee is not eligible for continued benefits, the claim administrator shall check
the appropriate box in Section 8, print their name and date on the bottom of the form and
send a copy of the form to the RI Department of Labor and Training, Division of
Workers’ Compensation, the employer, and the employee and his or her attorney.
7.
In the event that a dispute exists regarding benefits, either party may file a petition at the
Workers’ Compensation Court pursuant to Rhode Island General Law §28-35-11.
8.
If the employee may be eligible for continued benefits, the claim administrator shall
complete the appropriate Section(s) 9 and/or 10. In determining the offset, the following
must be considered.
A. If the employee did contribute to their retirement benefits, Section 9 must be
completed. The total amount of employee’s exclusive contribution is divided
by the weekly retirement benefit amount. The resulting figure will be the
number of weeks where there is no offset of workers’ compensation benefits.
If necessary, Section 10 would be completed to determine the amount of
offset that will occur after the completion of the non-offset weeks.
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