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Rescind Notice Of Claim Of Common Law Rights DWC-11R - Rhode Island
| Rescind 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 RESCIND NOTICE OF CLAIM OF COMMON LAW RIGHTS PURSUANT TO R.I.G.L. 28 - 29 -19 I, Name Soc. Sec. No. Address Date of Birth an employee, or former employee of the following business, Name DBA Address FEIN do hereby give notice in writing that I rescind my claim to right of act ion at common law to recover damages for personal injuries sustained while in the employment of the aforementioned employer. I understand that by rescinding this claim, I waive my right of action at common law to recover damages for personal injuries, and I may be eligible for workers compensation benefits pursuant to Title 28, Chapter 29, of the R.I. Workers Compensation l aw. 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 of this form. Pleas e enclose a check or money order payable to Rhode Island Department of Labor and Tra ining. The 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 envelope provided. DWC-11R (1/2002)
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