State of Rhode Island, Department of Labor and Training, Workers' Compensation Unit P.O. Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD 462-8006 NOTICE OF CLAIM OF COMMON LAW RIGHTS PURSUANT TO R.I.G.L. §28-29-17 I, Name Address Soc. Sec. No. Date of Birth an employee of the following business, Name Address DBA FEIN do hereby give notice in writing that I claim my right of action at common law to recover damages for personal injuries sustained while in the employment of the aforementioned employer. I understand that by claiming this right, I am no longer eligible for nor entitled to workers' compensation coverage or benefits pursuant to Title 28, Chapter 29, of the R.I. Workers' Compensation law. Under penalties of perjury I declare that I have examined this form and to the best of my knowledge it is true, correct and complete. I further acknowledge that false statements on the within document may subject me to criminal prosecution. Signature _________________________ Notary Public Signature ________________________ Date _____________________________ Date Commission Expires _______________________ A filing fee of five dollars ($5.00) is required with the submission of this form. Please enclose a check or money order payable to Rhode Island Department of Labor and Training. The employer should retain a copy of this form and send an original to the Department of Labor and Training. The employee and employer will receive a confirmation of the filing from the Department of Labor and Training. DWC-11 (6/2011) American LegalNet, Inc. www.FormsWorkFlow.com