Fill and Sign the Employers First Report for Workers Compensation Rhode Island Form

MF                                                                                                                        DWC No.:      Insurer's No.:       FEIN       Name       Address       City, state, zip       Name      Address       City, state, zip       Type of business       SIC Code       FEIN             FEIN       Name       Address       City, state, zip                                          Time of Injury       Time workday began       am am pin pin Date employer notified       First full day lost from work       yes yes yes no no no yes no Describe how the injury occurred                               Name       Address       City, state, zip       Phone       Address      City, state, zip       Phone                  - - ( ) - / / ( ) - ( ) - / / / / / / EMPLOYER'S FIRST REPORT OF INJURY State of Rhode Island Department of Labor Division of Workers' Compensation 610 Manton Ave., P.O. Box 3500 Providence, RI 02909-0500 Phone: (401) 272-0700 TDD: (401) 457-1888 EMPLOYEE INFORMATION:EMPLOYER INFORMATION: Soc. sec. no. Phone Date of birth Phone INSURANCE CARRIER: ADJUSTING COMPANY: Nam e Address City, state, zip Phone Phone INJURY INFORMATION: Injury date Place where injury occurred (include city and state) Injury occurred on employer's premises? Employee paid in full for day of injury? Has employee returned to work? Has the employee died? If yes, date returned to work If yes, date of death Give the injured body parts and the kind of injury sustained. (Examples: Broken left index finger, lower back strain, heart attack, etc.) MEDICAL INFORMATION: WITNESS INFORMATION: Treatment facility EMPLOYER'S SIGNATURE DATE FOR DIVISION USE: ONLY SIC OWN COUNTY TIME A TIME W DOB GENDER LOS OCC NATURE PART SOURCE TYPE AOS DWC-01 (10/92) CK0669 08-97