Free Employee's Petition To Review  - Rhode Island


File Size: 148.3 kB
Pages: 1
Date: October 16, 2008
File Format: PDF
State: Rhode Island
Category: Workers Compensation
Author: maveno
Word Count: 496 Words, 4,157 Characters
Page Size: 612 x 1008 pts
URL

http://www.courts.ri.gov/workers/forms/Interactive_Employees_Petition_to_Review.pdf

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W.C.C. # of pending petitions:

__________________________ __________________________

State of Rhode Island and Providence Plantations Providence, SC. Workers' Compensation Court
___________________________________________
Name of Employee-Petitioner

W.C.C. # __________________________________

XXX-XX- __________________________________
Social Security Number (last 4 digits only)

___________________________________________
Name of Employer-Respondent

___________________________________________
Address of Employer-Respondent

___________________________________________
Name of Agent for Service of Process

___________________________________________
Insurance Carrier

___________________________________________
Address of Agent for Service of Process

Employee's Petition to Review and/or Amend Agreement or Decree Concerning Compensation
The undersigned EMPLOYEE hereby petitions for a determination of my right to benefits under a compensation agreement, or under a decree of the Workers' Compensation Court. A copy of said agreement or decree establishing the liability of the employer to pay workers' compensation benefits is filed herewith. The undersigned affirms that the following facts are true:

1.

My incapacity for work has increased or returned by reason of the effects of the injury set forth in said agreement or decree attached hereto. Total incapacity from ____________ to ____________. Partial incapacity from ____________ to ____________. My employer refuses to provide or pay for necessary medical services as provided by R.I.G.L. 28-33-5 and 28-33-8, specifically____________________________________________________________. My employer and/or its insurance carrier refuse to give written permission for major surgery, specifically:

2.

3.

_________________________________________________________________________.
(Attach a copy of doctor's request for surgery) 4. Weekly payments of compensation have been based on an erroneous average weekly wage. My average weekly wage at the time of my injury was $ ____________. The compensation agreement or decree was procured by fraud, coercion or mutual mistake of fact. The compensation agreement or decree does not accurately and completely set forth and describe the nature and location of all injuries sustained by me. Said agreement or decree should be amended so that the nature and location of my injuries shall read as follows: ___________________________________________

5. 6.

_______________________________________________________________________ _________________________________________________________________________.
7. Per R.I.G.L. 28-33-18.3, I have received a notice of intention to terminate partial incapacity benefits pursuant to R.I.G.L. 28-33-18(d), and I hereby petition the court for continuation of benefits. Per R.I.G.L. 28-33-41 and the W.C.C. Rules of Practice, I hereby petition the court for a rehabilitation program approval. Per R.I.G.L. 28-33-47 and the W.C.C. Rules of Practice, I hereby petition the court for my right of reinstatement.

8.

9.

10. Per R.I.G.L. 28-33-18.2, I hereby petition the court for a finding of suitable alternative employment. 11. Per R.I.G.L. 28-33-20, I hereby petition the court for an order compelling the employer to provide a wage transcript. 12. Other: ______________________________________________________________________.

__________________________
Attorney Name

___________________________
Attorney Signature

___________________________
Signature of Employee

__________________________
Attorney Address and Phone Number

___________________________
Date

___________________________
Employee's Address

__________________________
City, State, Zip Code

___________________________
Attorney Bar Registration No.

___________________________
City, State, Zip Code

File the original and three copies with the appropriate attachments with the Office of the Administrator of the Workers' Compensation Court, J. Joseph Garrahy Judicial Complex, One Dorrance Plaza, Providence, Rhode Island 02903-3973. Distribution: White: Court Yellow: Employee Pink: Employer Gold: Insurer Rev 02/08