NOTIFICATION OF CLAIM OF COMPENSABLE INJURY TO BE SUBMITTED TO INSURER WITHIN THREE (3) DAYS OF INITIAL VISIT WITH A COPY TO THE EMPLO YEE AND HIS OR HER ATTORNEY DWC/MAB #: _________________________ IN SURERS #:_______________________ EMPLOYEE INFORMATION: EMPLOYER INFORMATION: Social security # ______________________________ FEIN # ______________________________________ Name ______________________________________ Name _______________________________________ Address ____________________________________ Address _____________________________________ City _________________ State_____ Zip _________ City _________________ State_____ Zip _________ Phone _____________________ DOB ____________ Phone ______________________________________ INSURANCE CARRIER: ADJUSTING COMPANY: Name ______________________________________ Name _______________________________________ Address ____________________________________ Address _____________________________________ City _________________ State_____ Zip _________ City _________________ State_____ Zip _________ Phone ______________________________________ Phone ______________________________________ Injury Date __________________________________ IF THE IDENTITY OF THE INSURER IS UNKNOWN, CONTACT THE DIVISION OF WORKERS COMPENSATION AT (401) 462-8116 FOR THE INFORMATION. SECTION 28-33-8(b) OF THE RHODE ISLAND WORKERS COMPENSATION ACT PROVIDES FOR A $20.00 FEE TO BE CHARGED FOR THE TIMELY FILING OF THIS FORM. 1. In the patients own words, relate how the injury happened: _______________________________________________ _________________________________________________________________________________________________ 2. Patients complaints (nature and location of injury) : _____________________________________________________ _________________________________________________________________________________________________ 3. Initial diagnosis: _________________________________________________________________________________ 4. Description of employees job: ______________________________________________________________________ _________________________________________________________________________________________________ 5a. Is the patient released to work, full duty? __ Yes __ No If the answer is YES, there is no need to submit a return to work form. 5b. If the answer to 5a is NO, indicate anticipated return to work date: Modified RTW date: _______________ Regular RTW date: _______________ 6. Date(s) of examination on which this report is based: ____________________________________________________ Are you continuing treatment? __ Yes __ No If YES, when will patient be seen again? _____________________ Physicians Signature__________________________________________ Date ________________________________ Physicians Name ________________________________ Treatment Facility ______________________________ Physicians Assistant Signature _______________________________________________________________________ Supervising Physicians Name ________________________________________________________________________ Physicians Address ________________________________________________________________________________ DWC-29 (4/02) RI Department of Labor & Training, Division of Workers Compensation