Fill and Sign the Workers Compensation Court Rhode Island Courts Form

W.C.C. # of pending cases : __________________________ __________________________ State of Rhode Island and Providence Plantations Providence, SC. Workers’ Compensation Court Petition Coversheet W.C.C. # ________________________ Petitioner: Respondent: ___________________________________ ___________________________________ Petitioner Name ___________________________________ Respondent Name ___________________________________ Address ___________________________________ Address ___________________________________ ___________________________________ Social Security Number Insurer: Agent for Service (employee petitions only): ___________________________________ ___________________________________ Insurer Name ___________________________________ Agent Name ___________________________________ Address ___________________________________ Address ___________________________________ Physician/Hospital (medical petitions only): Patient (medical petitions only): ___________________________________ ___________________________________ Physician/Hospital Name ___________________________________ Physician/Hospital Name ___________________________________ Address ___________________________________ Address ___________________________________ Petitioner’s Attorney :___________________________________ Bar No.: _________________________________________________ Respondent’s Attorney: _________________________________ Bar No.: _________________________________________________ Nature of Proceeding – Check the applicable case type (check one only) AL ADJUDGE IN COMTEMPT-DEPT OF LABOR RR EE’S PET TO ADJ EMPR IN CONTPT AR ANNUAL COURT REVIEW RS ER’S PET FOR RELIEF UNDER SIIF AY ASSESS OF PENALTY-DEPT OF LABOR RW ER’S PET FOR REHAB PROGRAM REV DE ENFORCE DIRECTOR’S ORDER SP EE’S PETITION SPECIFIC COMP DH DEATH BENEFIT CO COMMUTATION EE EMPLOYEES PETITION TO REVIEW DC DETERMINATION OF CONTROVERSY EF PETITION TO ENFORCE DR DIRECTOR’S REVIEW EG EE’S RIGHT TO REINSTATEMENT ED ER’S DISPUTE OF INSUR. COVERAGE EO EMP PET REV-DIRECTORS ORDER EU EE’S PET FOR RELIEF UNDER SIIF EP EE’S PET TO AMEND PA OR DCRE EW EE’S APPEALS FROM DEPT FOR DNV ER EMPLOYER’S PETITION TO REVIEW IC INS’S DISPUTE OF INSUR. COVERAGE ES ENFORCE DIRECTOR’S SUS ORDER MA MEDICAL ADVISORY BOARD APPEAL HP HOSPITAL PETITION NS EMPLOYER’S NOTICE TO SUSPEND MD EE’S PET TO REVIEW – MEDICAL PAY RM ER’S APPEALS FROM DEPT FOR DNV MS MISCELLANEOUS RO ER’S PET REV-DIRECTORS ORDER OP ORIGINAL PETITION RQ REQ PERMISISION FOR MAJOR SURG PP PHYSICIAN’S PETITION SM SETTLEMENT OF DISPUTED CLAIMS RD ER’S PET TO AMEND PA OR DCRE WO STOP WORK ORDER RH EE’S PET FOR REHAB PROGRAM REV Revised 02/08