Employees Petition For Compensation Benefits | Pdf Fpdf Doc Docx | Rhode Island

Employees Petition For Compensation Benefits

Rhode Island/Workers Comp/Workers Compensation Court/
Employees Petition For Compensation Benefits | Pdf Fpdf Doc Docx | Rhode Island

Employees Petition For Compensation Benefits Form

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This is a Rhode Island form that can be used for Workers Compensation Court within Workers Comp.

Last updated: 11/30/2016
W.C.C. Pending Petitions: State of Rhode Island and Providence Plantations Providence, SC. Workers' CompensationCourt Employee's Petition for Compensation Benefits 1. NAME OF INJURED EMPLOYEE ­ Petitioner Social Security Number 6. NAME OF EMPLOYER - Respondent XXX ­ XX ­ 2. HOME ADDRESS (Street, No., City or Town, State and Zip Code) (last 4 digits only) 7. BUSINESS ADDRESS (Street, No., City or Town, State and Zip Code) 8a. NAME OF AGENT FOR SERVICE OF PROCESS 3. DESCRIPTION OF EMPLOYEE'S JOB 8b. ADDRESS OF AGENT FOR SERVICE OF PROCESS 4. NATURE OF EMPLOYER'S BUSINESS 9. NAME OF EMPLOYER'S INSURANCE CARRIER ON DATE OF ALLEGED INJURY DID INJURY OCCUR ON EMPLOYER'S PREMISES? Yes No 5. DATE OF ALLEGED INJURY (MONTH, DAY, YEAR, TIME) 10. 11. IF NOT ON EMPLOYER'S PREMISES, WHERE DID INJURY OCCUR? 12. NAME(S) AND ADDRESS (ES) OF WITNESS (ES) TO INJURY 13. HOW DID INJURY OCCUR? 14. NATURE OF INJURY AND PARTS OF BODY AFFECTED BY INJURY 15. NAME(S) OF PHYSCIAN(S) AND HOSPITAL(S) WHO HAVE RENDERED SERVICES 16. WEEKLY WAGES AT TIME OF INJURY 17. FIRST DAY OF LOST TIME 18. (a) DID YOU RECEIVE WAGES FROM YOUR EMPLOYER WHILE ABSENT FROM WORK? Yes No (b) IF SO, TO WHAT DATE? W.C.C. 9 (Rev 02/15) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 19. (a) DID YOU RETURN TO WORK FOLLOWING THE INJURY? Yes No (b) IF SO, WHAT DATE? 20. (a) FOR WHOM DID YOU RETURN TO WORK (Give Name and Address)? (b) AT WHAT WEEKLY WAGE? 21. NAME AND TITLE OF PERSON IN EMPLOY OF YOUR EMPLOYER WHOM YOU NOTIFIED, OR WHO HAD KNOWLEDGE OF YOUR INJURY 22. (a) DID YOU RECEIVE WORKERS' COMPENSATION BENEFITS FROM YOUR EMPLOYER OR THEIR INSURER FOR THE ABOVE INJURY? Yes No (b) IF SO, TO WHAT DATE? 23. WAS A NON-PREJUDICIAL AGREEMENT CONCERNING COMPENSATION BENEFITS ENTERED INTO WITH YOUR EMPLOYER OR THEIR INSURER? Yes No CHECK BELOW THE BENEFITS YOU ARE SEEKING TOTAL DISABILITY COMPENSATION PARTIAL DISABILITY COMPENSATION MEDICAL BENEFITS NO LOST TIME NAME OF DEPENDENT SPOUSE AND NAMES AND AGES OF DEPENDENT CHILDREN AS DEFINED IN R.I.G.L. § 28-33-17. FROM FROM TO TO PERMISSION TO HAVE MAJOR SURGERY PERFORMED, NAMELY: SPECIFIC COMPENSATION CONCERNING THE FOLLOWING BODILY MEMBER (S) OR FUNCTION (S): COUNSEL, WITNESS AND SHERIFF'S FEES Name of Attorney Signature of Employee Address and Phone Number of Attorney Bar Registration Number Signature of Attorney W.C.C. 9 (Rev 02/15) Date W.C.C. 9 (Rev 02/15) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2