State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORT EMPLOYER'S FIRST REPORT OF ALLEGED OCCUPATIONAL INJURY, DISEASE OR FATALITY Department of Labor and Training, Division of Workers' Compensation DWC No. PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (401) 462-8006 FAX (401) 462-8105 1. EMPLOYER LOCATION: FEIN Name Address City, State, Zip Phone RI Unemployment Ins. No. 3. INSURANCE COMPANY NAMED ON WC POLICY: FEIN Name Address Address City, State, Zip Phone 5. EMPLOYEE INFORMATION: SSN Name Address City, State, Zip Phone Occupation State of Hire 8. INJURY INFORMATION: Injury Date Time injury occurred Time employee began work 1. First full day lost from work 2. Date returned to work (if appropriate) 3. Date employer notified of injury If fatal - REPORT WITHIN 48 HOURS - Date of death Place where injury/illness occurred: At employer location listed in Block 1 OR Complete address where accident occurred: Insurer File No. 2. EMPLOYER NAMED ON WC INSURANCE POLICY: FEIN Name Address City, State, Zip SAME AS BLOCK 1 Ext. Type of Business NAICS Phone WC Policy Number 4. CLAIM ADMINISTRATOR: FEIN Name Address Address City, State, Zip Ext. Phone 6. MEDICAL INFORMATION: Female Treatment Facility Address City, State, Zip Phone 7. WITNESS INFORMATION: Name Phone Ext. SAME AS BLOCK 3 Ext. Male Ext. Date of Birth Date Hired Preferred Language of Employee: O English O Spanish O Portuguese O Other: What was person doing when injured? AM AM PM PM List injured body parts and nature of injury:(ex: Broken left finger, lower back strain) NONE LOST Was this injury previously an incident-only with no medical treatment and no time lost? If Yes, date employer first notified of medical treatment or time lost Category(ies) of injury or illness: Print Name of Report Preparer Yes No O Injury O Illness O Occupational Disease O Repetitive Trauma O Occupational Hearing Loss Phone & Extension O Unknown Date Prepared Print Name of Employer Contact Person OR Same as above Phone & Extension DWC: County DWC-01 (01/03) Time A Time W OCC Nature Part Source Type For instructions visit our web site: www.dlt.ri.gov/wc American LegalNet, Inc. www.FormsWorkFlow.com