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Sample Packet Revised 121123 Rhode Island Department of Form

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Sample packet revised 121123 rhode island department of form

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State of Rhode Island SUSPENSION AGREEMENT AND RECEIPT PLEASE CHECK IF CORRECTION OF PRIOR REPORT DWC No. Department of Labor and Training, Division of Workers' Compensation PO Box 20190, Cranston, RI 02920-0942 Phone (401)462-8100 TDD (401)462-8006 Insurer File No. 1. EMPLOYEE INFORMATION: 2. CLAIM INFORMATION: SSN Employer Name Insurance Co. Address Claim Administrator City, State, Zip Injury date Phone Incapacity date We that which on compensation weekly began agree will of of incapacity) end as (date (date paid through). Payment of medical bills related to this injury may continue. Completing and signing this form does not prevent the employee from claiming future weekly compensation benefits in the event that the employee is unable to work due to this injury. Date: Employee Signature: Date: Employer or Insurer Signature: For instructions visit our web site: www.d1t.ri.gov/wc DWC-05 (01/03)

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Fill and Sign the Sample Packet Revised 121123 Rhode Island Department of Form