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Employees Petition To Review And Or Amend Agreement Or Decree Concerning Compensation - Rhode Island
| Employees Petition To Review And Or Amend Agreement Or Decree Concerning Compensation Form. This is a Rhode Island form and can be used in Workers Compensation Court Workers Comp . |
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W.C.C. # of pending petitions: __________________________ __________________________ Providence, SC. Name of Employee-Petitioner State of Rhode Island and Providence Plantations Workers' Compensation Court 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 Date Attorney Bar Registration No. Signature of Employee Employee's Address City, State, Zip Code __________________________ Attorney Address and Phone Number ___________________________ ___________________________ ___________________________ ___________________________ __________________________ 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 American LegalNet, Inc. www.FormsWorkflow.com
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