Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 3
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18State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
EMPLOYER'S FIRST REPORT OF ALLEGED OCCUPATIONAL INJURY, DISEASE OR FATALITY
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 FAX (401) 462-8105
Insurer File No.
1. EMPLOYER LOCATION:
2. EMPLOYER NAMED ON WC INSURANCE POLICY:
SAME AS BLOCK 1
FEIN
FEIN
Name
Name
Address
Address
City, State, Zip
City, State, Zip
Phone
Ext.
Type of Business
Phone
Ext.
RI Unemployment Ins. No.
NAICS
WC Policy Number
3. INSURANCE COMPANY NAMED ON WC POLICY:
4. CLAIM ADMINISTRATOR:
SAME AS BLOCK 3
FEIN
FEIN
Name
Name
Address
Address
Address
Address
City, State, Zip
City, State, Zip
Phone
Ext.
Phone
Ext.
5. EMPLOYEE INFORMATION:
6. MEDICAL INFORMATION:
Male
SSN
Female
Treatment Facility
Name
Address
Address
City, State, Zip
City, State, Zip
Phone
Ext.
7. WITNESS INFORMATION:
Phone
Date of Birth
Occupation
Date Hired
Name
Phone
O
O
O
O
State of Hire
Preferred Language of Employee:
English
Spanish
Portuguese
Other:
8. INJURY INFORMATION:
What was person doing when injured?
Injury Date
Time injury occurred
AM
PM
Time employee began work
AM
PM
1. First full day lost from work
NONE LOST
List injured body parts and nature of injury:(ex: Broken left finger, lower back strain)
2. Date returned to work (if appropriate)
3. Date employer notified of injury
If fatal - REPORT WITHIN 48 HOURS - Date of death
Complete address where accident occurred:
Place where injury/illness occurred:
At employer location listed in Block 1 OR
Was this injury previously an incident-only with no medical treatment and no time lost?
Yes
No
If Yes, date employer first notified of medical treatment or time lost
O
O
O
O
O
O
Category(ies) of injury or illness:
Injury
Illness
Occupational Disease
Repetitive Trauma
Occupational Hearing Loss
Unknown
Print Name of Report Preparer
Date Prepared
Phone & Extension
Print Name of Employer Contact Person OR
Same as above
Phone & Extension
County
Time A
Time W
OCC
Nature
Part
Source
Type
For instructions visit our web site:
DWC-01 (01/03)
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Parent category: Business