Fill and Sign the Ri Workers Compensation Form

MF                                                                                                            DWC File No.      Insurer File No.;       FEIN       Name       Address       City, state, zip       Name      Address       City, state, zip             Type of business       SIC Code       FEIN       FEIN       Name       Address       City, state, zip       Contact Person       Contact Person       Injury Date       Incapacity Date       Name             Application accepted Application rejected       Date             - - ( ) - / / ( ) - / / ( ) - / / RI DEPARTMENT OF LABOR .vCRMvCCWORKERS COMPENSATION ADMINISTRATION FUNDProvidence, RI 02909-0500 510 Manton Ave, P.O.. Box 3500 Providenc e 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. EMPLOYEE INFORMATION: Soc. sec. no. EMPLOYER INFORMATION: Phone Date of birth Phone Occupation Date Employed INSURANCE CARRIER: ADJUSTING COMPANY: Nam e Address City, state, zip Phone Phone INJURY INFORMATION Signature Date WCAF USE ONLY: Examiner