Claim Administrator Claim Number Employee Information Employer, Insurer & Claim Administrator AgreementRI Department of Labor and Training, Division of Workers' CompensationPO Box 20190, Cranston, RI 02920-0942www.dlt.ri.gov/wc Phone 401-462-8100 Fax 401-462-8105 SSN or IDDate of Birth Last Name First Name Initial Date of Injury Employer NameInsurer NameDate of Claim Administrator Name Employee Signature Signature Date Employee Signature Date American LegalNet, Inc. www.FormsWorkFlow.com