Form Dwc-01 - Employer'S First Report Of Alleged Occupational Injury, Disease Or Fatality Page 9
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18State of Rhode Island
PLEASE CHECK IF CORRECTION OF PRIOR REPORT
SUSPENSION AGREEMENT AND RECEIPT
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
We
agree
that
weekly
compensation
which
began
on
____________________(date of incapacity) will end as of
____________________(date paid through). Payment of medical
bills related to this injury may continue. Completing and signing
this form does not prevent the employee from claiming future
weekly compensation benefits in the event that the employee is
unable to work due to this injury.
Employee Signature:
Date:
Employer or Insurer Signature:
Date:
For instructions visit our web site:
DWC-05 (01/03)
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