Report an Injury for Rhode Island

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EMPLOYER'S FIRST REPORT OF INJURY

Fields marked with an asterisk (*) are required—you cannot submit the form unless these fields are completed.

 
PLEASE CHECK IF CORRECTION OF PRIOR REPORT


2. EMPLOYER NAMED ON WC INSURANCE POLICY


4. CLAIM ADMINISTRATOR

5b. Sex*
5i. Employee Status*
5k. Preferred Language of Employee




8a. Injury Date*
8d. First full day lost from work*
8e. Date returned to work
8f. Date employer notified of injury *
8g. If fatal – REPORT WITHIN 48 HOURS – Date of death
8h. Place where injury/illness occurred.
8i. Was this injury previously an incident-only with no medical treatment and no time lost?
Date Employer First Notified of Medical Treatment or Time Lost
8j. Category(ies) of injury or illness *







Date Prepared: *
1. Attachment field (medical records)
( 9.5mb limit for all files )
X

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