State of Rhode Island and Providence Plantations Providence, Sc. Workers' Compensation Court vs. Employees' Retirement System of Rhode Island } W.C.C. No. STATEMENT OF CLAIM Name of Injured Employee: Address: Date of Birth: Occupation: Social Security Number: XXX-XX- Date of Hire: (last 4 digits only) Name of Agency/Municipality: Address: Police: Fire: Agent for Service: Address: Date of Injury: Page 1 of 2 W.C.C. IOD-03 (7/15) American LegalNet, Inc. www.FormsWorkFlow.com W.C.C. No. Nature and Location of Employee's Injury: First Date of Incapacity: Is Employee Receiving IOD Benefits? Date of Decision of the Retirement Board: Name of Treating Physician(s): Yes No If yes, effective date: Name of any/all Medical Examiners for the Agency/Municipality: Employee Name Attorney Name Attorney's Signature Attorney Address and Phone Number Date Attorney Bar Registration Number Page 2 of 2 W.C.C. IOD-03 (7/15) American LegalNet, Inc. www.FormsWorkFlow.com