State of Rhode Island SUSPENSION AGREEMENT AND RECEIPT Department of Labor and Training, Division of Workers' Compensation PO Box 20190, Cranston, RI 02920-0942 PLEASE CHECK IF CORRECTION OF PRIOR REPORT DWC No. Insurer File No. Phone (401) 462-8100 TDD (401) 462-8006 1. EMPLOYEE INFORMATION: SSN Name Address City, State, Zip Phone 2. CLAIM INFORMATION: Employer Insurance Co. Claim Administrator Injury date 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: DWC-05 (01/03) For instructions visit our web site: www.dlt.ri.gov/wc American LegalNet, Inc. www.FormsWorkFlow.com