Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 15
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18State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
EMPLOYEE'S OBJECTION TO WAGE TRANSCRIPT
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
The employee objects to the discontinuance or
reduction
of
workers'
compensation
benefits
pursuant to RIGL Section 28-35-47 and requests a
review by the Workers' Compensation Court,
pursuant to RIGL Section 28-35-51.
Employee:
Date:
For instructions visit our web site:
DWC-31 (01/03)
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