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Notice Of Claim Of Common Law Rights DWC-11 - Rhode Island
| Notice Of Claim Of Common Law Rights Form. This is a Rhode Island form and can be used in Compliance Department Of Labor And Training Workers Comp . |
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State of Rhode Island, Department of Labor and Training, Workers Com pensation Unit P.O. Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD 462-8006 NOTICE OF CLAIM OF COMMON LAW RIGHTS PURSUANT TO R.I.G.L. 28 -29 - 17 I, Name Soc. Sec. No. Address Date of Birth an employee of the following business, Name DBA Address FEIN do hereby give notice in writing that I claim my right of action at com mon law to recover damages for personal injuries sustained while in the employment of the aforementioned employer. I understand that by claiming this right, I am no longer eligible for no r entitled to workers compensation coverage or benefits pursuant to Title 28, Chapter 29, of t he R.I. Workers Compensation law. Under penalties of perjury I declare that I have examined this form and to the best of my knowledge it is true, correct and complete. I further acknowledge that false statements on the within document may subject me to criminal prosecution. Signature _______________ __________ Notary Public Signature ________________________ Date _____________________________ Date Commission Expires _______________________ A filing fee of five dollars ($5.00) is required with the submission o f this form. Please enclose a check or money order payable to Rhode Island Department of Labor and Training. T he employer should retain a copy of this form and send an original to the Department of Labor and Training. For a dated receipt copy, include a copy with the original sent to the D epartment with a self addressed, stamped envelope. The original and copy will be date stamped . The original will be retained for our files. The stamped copy will be returned in the envelo pe provided. DWC-11 (1/2002)
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