Page 1 of 2 Rev 10/17 State of Rhode Island and Providence Plantations Providence, S c . Workers 222 Compensation Court W.C.C. No. Name of Employee - Petitioner Date of Birth (mm/dd/yyyy) Date of Injury Name of Employer - Respondent Address of Employer - Respondent Name of Agent for Service of Process Insurance Carr ier Address of Agent for Service of Process Employee222s Petition to Review and/or Amend Agreement or Decree Concerning Compensation The undersigned EMPLOYEE hereby petitions for a determination of my right to benefits under a compensation agreement, or under a decree of the Workers222 Compensation Court. A copy of said agreement or decree establishing the liability of the employer to pay workers222 compensation benefits is filed herewith. The undersigned affirms that the following facts are true: 1. My incapacity for work has increased or returned by reason of the effects of the injury set forth in said agreement or decree attached hereto. Total incapacity from to . Part ial incapacity from to . 2. My employer refuses to provide or pay for necessary medical services as provided by R.I.G.L. 247247 28-33-5 and 28-33-8, specifically . 3. My employer and/or its insurance carrier refuse to give written permission for major surgery, specifically: . (Attach a copy of doctor222s request for surgery) 4. Weekly paymen ts of compensation have been based on an erroneous average weekly wage. My average weekly wage at the time of my injury was $ . W.C.C. # of pending petitions : American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Rev 10/17 W.C.C. No. 5. The compensation agreement or decree was procured by fraud, coercion or mutu al mistake of fact. 6. The compensation agreement or decree does not accurately and completely set forth and describe the nature and location of all injuries sustained by me. Said agreement or decree should be amended so that the nature and location of my injuries shall read as follows: 7. Per R.I.G.L. 247 28 - 33 - 18.3 , I have received a notice of intention to terminate partial incapacity benefits pursuant to R.I.G.L. 247 28-33-18(d), and I hereby petition the court for continuation of benefits. 8. P er R.I.G.L. 247 28 - 33 - 41 and the W.C.C. Rules of Practice, I hereby petition the court for a r ehabilitation p rogram a pproval. 9. Per R.I.G.L. 247 28 - 33 - 47 and the W.C.C. Rules of Practice, I hereby petition the court for my r ight of r einstatement. 10. Per R .I.G.L. 247 28 - 33 - 18.2 , I hereby petition the court for a finding of s uitable a lternative e mployment. 11. Per R.I.G.L. 247 28 - 33 - 20 , I hereby petition the court for an order compelling the employer to provide a wage transcript. 12. Other : Attorney Name and Phone Number Attorney Signature Signature of Employee Attorney A ddress Date Employee222s Address City, State, Zip Code Attorney Bar Registration No . City, State, Zip Code American LegalNet, Inc. www.FormsWorkFlow.com