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Petition For Compensation Benefits Of Deceased Employee - Rhode Island
| Petition For Compensation Benefits Of Deceased Employee 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 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. HOW DID INJURY OCCUR? NATURE AND EXTENT OF INJURY 16. 17. 19 20. 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 Signature of Petitioner Print Name of Petitioner Attorney Bar Registration Number 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 American LegalNet, Inc. www.FormsWorkflow.com
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