Free Petition for Deceased Employee Benefits - Rhode Island

W.C.C. # of pending cases: __________________________ __________________________

Providence, SC.
1 NAME OF PETITONER

State of Rhode Island and Providence Plantations Workers' Compensation Court
Petition For Compensation Benefits of Deceased Employee
Social Security Number XXX ­ XX ­
(last 4 digits only)

7.

NAME OF EMPLOYER OF DECEASED EMPLOYEE

(Respondent)

2.

RELATIONSHIP OF PETITIONER TO DECEASED EMPLOYEE

8.

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

3.

PETITIONER'S ADDRESS (Street, No., City or Town, State and Zip Code)

9.

NAME AND ADDRESS OF AGENT FOR SERVICE OF PROCESS

4.

NAME OF DECEASED EMPLOYEE

Social Security Number XXX ­ XX ­
(last 4 digits only)

10.

NAME OF EMPLOYER'S INSURANCE CARRIER ON DATE OF ALLEGED INJURY

5.

DATE AND PLACE OF DEATH OF EMPLOYEE

11.

NATURE OF EMPLOYER'S BUSINESS

6.

DATE OF ALLEGED INJURY (Month, Day, Year, Time)

12.

DID INJURY OCCUR ON EMPLOYER'S PREMISES? IF NOT, WHERE DID INJURY OCCUR?

Yes

No

13.

NAME(S) AND ADDRESS(ES) OF WITNESS(ES) TO INJURY

14. 15. 16. 17. 19 20.

HOW DID INJURY OCCUR? NATURE AND EXTENT OF INJURY NAME(S) OF PHYSICIAN(S) AND HOSPITAL(S) WHO RENDERED SERVICES WEEKLY WAGES AT TIME OF INJURY 18. FIRST DAY OF LOST TIME FROM WORK

NAME AND TITLE OF PERSON IN EMPLOY OF EMPLOYER, WHO WAS NOTIFIED OR WHO HAD KNOWLEDGE OF INJURY TO DECEASED DID DECEASED EMPLOYEE RECEIVE WORKERS' COMPENSATION BENEFITS FOR THE ABOVE INJURY? No UNDER A MEMORANDUM OF AGREEMENT? UNDER A NON-PREDJUDICIAL AGREEMENT? Yes UNDER A DECREE OF THE WORKERS' COMPENSATION COURT? Yes No NAME OF ADMINISTRATOR(S) OR EXECUTOR(S)

Yes

No

21, 22.

WAS AN ESTATE OPENED?

Yes

No

IF SO WHERE?

NAME OF PERSON PAYING BURIAL EXPENSES, AND AMOUNT PAID

NAME, ADDRESS, RELATIONSHIP, AND DATES OF BIRTH OF ALL DEPENDENTS OF DECEASED EMPLOYEE WHO WERE DEPENDENT AT THE TIME OF INJURY OR DEATH. NAME ADDRESS RELATIONSHIP TO DECEASED EMPLOYEE DATE OF BIRTH OF MINORS

CHECK THE BENEFITS YOU ARE SEEKING: WEEKLY BENEFITS PURSUANT TO R.I.G.L. §§ 28-33-12 AND 28-33-23 FUNERAL EXPENSES PURSUANT TO R.I.G.L. § 28-33-16 OTHER, PLEASE SPECIFY I hereby petition that my rights to benefits under the Workers' Compensation Act may be determined, and in support of this pleading I make the foregoing statements of fact: that both said employer and deceased employee were subject to the provisions of the Workers' Compensation Act; that said employee's injury was not occasioned by the employee's willful intention to bring about the injury or death of himself/herself or another; and that said injury did not result from the employee's intoxication on duty or unlawful use of controlled substances. I have attached a duly certified copy of the certificate of death along with any agreement or decree to pay workers' compensation benefits, if applicable.

Attorney Name Attorney Address and Phone Number Attorney Bar Registration Number

Signature of Petitioner Print Name of Petitioner Date

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: Original Yellow: Agent for Service of Process/Employer Pink: Dependent/Attorney Gold: Insurance Carrier Rev 02/08