Free Original Petition  - Rhode Island

W.C.C. # of pending cases:

__________________________ __________________________

Providence, SC.
1.

State of Rhode Island and Providence Plantations Workers' Compensation Court
Employee's Petition for Compensation Benefits
Social Security Number 6. NAME OF EMPLOYER - Respondent

NAME OF INJURED EMPLOYEE ­ Petitioner

XXX ­ XX ­
(last 4 digits only)

2.

HOME ADDRESS (Street, No., City or Town, State and Zip Code)

7.

BUSINESS ADDRESS (Street, No., City or Town, State and Zip Code)

Date of Birth 3. DESCRIPTION OF EMPLOYEE'S JOB -

8a.

NAME OF AGENT FOR SERVICE OF PROCESS

8b.

ADDRESS OF AGENT FOR SERVICE OF PROCESS

4.

NATURE OF EMPLOYER'S BUSINESS

9.

NAME OF EMPLOYER'S INSURANCE CARRIER ON DATE OF ALLEGED INJURY DID INJURY OCCUR ON EMPLOYER'S PREMISES? Yes No

5.

DATE OF ALLEGED INJURY (MONTH, DAY, YEAR, TIME)

10.

11. IF NOT ON EMPLOYER'S PREMISES, WHERE DID INJURY OCCUR? ________________________________________________________________________________________________________________________________________________ 12. NAME(S) AND ADDRESS (ES) OF WITNESS (ES) TO INJURY ________________________________________________________________________________________________________________________________________________ 13. HOW DID INJURY OCCUR? ________________________________________________________________________________________________________________________________________________ 14. NATURE OF INJURY AND PARTS OF BODY AFFECTED BY INJURY ________________________________________________________________________________________________________________________________________________ 15. NAME(S) OF PHYSCIAN(S) AND HOSPITAL(S) WHO HAVE RENDERED SERVICES ________________________________________________________________________________________________________________________________________________ 16. WEEKLY WAGES AT TIME OF INJURY 17. FIRST DAY OF LOST TIME ________________________________________________________________________________________________________________________________________________ 18. (a) DID YOU RECEIVE WAGES FROM YOUR EMPLOYER WHILE ABSENT FROM WORK? (b) IF SO, TO WHAT DATE? Yes No ________________________________________________________________________________________________________________________________________________ 19. (a) DID YOU RETURN TO WORK FOLLOWING THE INJURY? (b) IF SO, WHAT DATE? Yes No ________________________________________________________________________________________________________________________________________________ 20. (a) FOR WHOM DID YOU RETURN TO WORK (Give Name and Address)? (b) AT WHAT WEEKLY WAGE? ________________________________________________________________________________________________________________________________________________ 21. NAME AND TITLE OF PERSON IN EMPLOY OF YOUR EMPLOYER WHOM YOU NOTIFIED, OR WHO HAD KNOWLEDGE OF YOUR INJURY ________________________________________________________________________________________________________________________________________________ 22. (a) DID YOU RECEIVE WORKERS' COMPENSATION BENEFITS FROM YOUR EMPLOYER OR THEIR INSURER FOR THE ABOVE INJURY? Yes No (b) IF SO, TO WHAT DATE? ________________________________________________________________________________________________________________________________________________ 23. WAS A NON-PREJUDICIAL AGREEMENT CONCERNING COMPENSATION BENEFITS ENTERED INTO WITH YOUR EMPLOYER OR THEIR INSURER? Yes No ________________________________________________________________________________________________________________________________________________ CHECK BELOW THE BENEFITS YOU ARE SEEKING TOTAL DISABILITY COMPENSATION FROM TO PARTIAL DISABILITY COMPENSATION MEDICAL BENEFITS NO LOST TIME NAME OF DEPENDENT SPOUSE AND NAMES AND BIRTH DATES OF DEPENDENT CHILDREN AS DEFINED IN R.I.G.L. § 28-33-17. FROM TO

PERMISSION TO HAVE MAJOR SURGERY PERFORMED, NAMELY: SPECIFIC COMPENSATION CONCERNING THE FOLLOWING BODILY MEMBER (S) OR FUNCTION (S): COUNSEL, WITNESS AND SHERIFF'S FEES ___________________________________________________ Name of Attorney ___________________________________________________ Address and Phone Number of Attorney ___________________________________________________ Bar Registration Number ___________________________________________________ Signature of Attorney (Rev 02/08) Distribution: White-Original/Pink-Agent for Service of Process-Employer/Gold-Employees Attorney/Yellow-Insurance Carrier/Blue-TDI/Green-DHS ___________________________________________________ Signature of Employee ___________________________________________________ Date