Fill and Sign the Ri Department of Labor Form

RI DEPARTMENT OF LABOR DWC File No. WORKERS COMPENSATION ADMINISTRATION FUND 510 Manton Ave, P.O.. Box 3500 Insurer File No.; APPLICATION FOR REIMBURSEMENT OF COST OF LIVING ADJUSTMENT PAYMENTS Under rules promulgated by the Director of the Department of Labor an insurance company may request reimbursement of payment for cost of living adjustment for injuries which occurred September 1, 1974 through December 31, 1993. Submit an application for acceptance of each injury. The Workers' Compensation Administrative Fund will review requests for reimbursement of payment for accepted injuries. This application must be completed in full, signed and mailed to the address above. Submission of this form constitutes application for acceptance of this injury for reimbursement of payments made for cost of living adjustment benefits. A request for reimbursement should accompany this application. INJURY INFORMATION Injury Date Incapacity Date Date Name Signature WCAF USE ONLY: Application accepted Date Examiner EMPLOYEE INFORMATION: Soc. sec. no. M F Name Address City, state, zip Phone Date of birth INSURANCE CARRIER: FEIN Name Address City, state, zip Phone EMPLOYER INFORMATION: FEIN Name Address City, state, zip Phone SIC Code Type of business ADJUSTING COMPANY: FEIN Name Address City, state, zip Phone Providence, RI 02909-0500 Occupation Date Employed Contact Person Contact Person Application rejected - - ( ) - / / / / ( ) - ( ) - / /