Report an Injury for Rhode Island

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

PLEASE CHECK IF CORRECTION OF PRIOR REPORT

Yes

DWC No

Insurer File Number

1. EMPLOYER LOCATION

1a. FEIN

1b. Employer Name*

1c. Street/P.O. Box Mailing Address:*

City*

State*

Zip*

1e. Phone Number*

1f. Extension

1g. Type of Business

1h. RI Unemployment Ins. No

1i. NAICS

2. EMPLOYER NAMED ON WC INSURANCE POLICY

Same as Block 1

2a. FEIN

2b. Employer Name *

2c. Street/P.O. Box Mailing Address*

2d. City*

State*

Zip*

2e. Phone Number*

2f. Extension

2e. WC Policy Number

3. INSURANCE COMPANY NAMED ON WC POLICY

3a. FEIN

3b. Insurance Company Named on Workers’ Compensation Policy *

A.I.M. Mutual Insurance Co. Associated Employers Insurance Co. New Hampshire Employers Insurance Co.

3c. Street/P.O. Box Mailing Address*

3d. Street/P.O. Box Mailing Address 2

3e. City *

State *

Zip *

3f. Phone Number

3g. Extension

4. CLAIM ADMINISTRATOR

Same as Block 3

4a. FEIN

4b. Insurance Company Named on Workers’ Compensation Policy*

A.I.M. Mutual Insurance Co. Associated Employers Insurance Co. New Hampshire Employers Insurance Co.

4c. Street/P.O. Box Mailing Address*

4d. Street/P.O. Box Mailing Address 2

4e. City*

State*

Zip*

4f. Phone Number

4g. Extension

5. EMPLOYEE INFORMATION

5a. Social Security Number*

5b. Sex*

Male Female Unknown

5c. Employee Name*

5d. Street/P.O. Box Mailing Address*

5e. City*

State*

Zip*

5f. Employee Phone Number

Phone Type

Home Cell Work

Employee Personal Email Address

5g. Date of Birth (mm/dd/yyyy)*

5h. Occupation/Job Title

5i. Date of Hire*

5i. Employee Status*

Full Time Part Time Seasonal

5j. State of Hire

5k. Preferred Language of Employee

English Spanish Portuguese Other

6. MEDICAL INFORMATION

6a. Treatment Facility

6b. Street/P.O. Box Mailing Address

6c. City

State

Zip

6d. Phone Number

6e. Extension

7. WITNESS INFORMATION

7a. Witness Name

7b. Phone Number

8. INJURY INFORMATION

8a. Injury Date*

8b. Time Injury Occurred

8c. Time employee began work

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.

Same as Block 1

Street/P.O. Box Mailing Address

City

State

Zip

Phone Number

Extension

8i. Was this injury previously an incident-only with no medical treatment and no time lost?

Yes No

Date Employer First Notified of Medical Treatment or Time Lost

8j. Category(ies) of injury or illness *

Injury
Illness
Occupational Disease
Repetitive Trauma
Occupational Hearing Loss
Unkown

8k. What was person doing when injured? *

8l.List injured body parts and nature of injury: (ex: Broken left finger, low back strain) *

Preparer name and title*

Date Prepared: *

Preparer phone

Preparer email address*

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