W.C.C. Pending Cases Providence, Sc. State of Rhode Island and Providence Plantations Workers' Compensation Court Petition For Compensation Benefits of Deceased Employee 1 NAME OF PETITIONER 7. NAME OF EMPLOYER OF DECEASED EMPLOYEE (Respondent) 2. RELATIONSHIP OF PETITIONER TO DECEASED EMPLOYEE 8. BUSINESS ADDRESS (Street, No., City or Town, State and Zip Code) 3. PETITIONER'S ADDRESS (Street, No., City or Town, State and Zip Code) 9. NAME AND ADDRESS OF AGENT FOR SERVICE OF PROCESS 4. NAME OF DECEASED EMPLOYEE 10. NAME OF EMPLOYER'S INSURANCE CARRIER ON DATE OF ALLEGED INJURY 5. DATE AND PLACE OF DEATH OF EMPLOYEE 11. NATURE OF EMPLOYER'S BUSINESS 6. DATE OF ALLEGED INJURY (Month, Day, Year, Time) 12. DID INJURY OCCUR ON EMPLOYER'S PREMISES? IF NOT, WHERE DID INJURY OCCUR? Yes No 13 . NAME(S) AND ADDRESS(ES) OF WITNESS(ES) TO INJURY 14 . 15 . 16 . 17 . 19 HOW DID INJURY OCCUR? NATURE AND EXTENT OF INJURY NAME(S) OF PHYSICIAN(S) AND HOSPITAL(S) WHO RENDERED SERVICES WEEKLY WAGES AT TIME OF INJURY 18. FIRST DAY OF LOST TIME FROM WORK NAME AND TITLE OF PERSON IN EMPLOY OF EMPLOYER, WHO WAS NOTIFIED OR WHO HAD KNOWLEDGE OF INJURY TO DECEASED Rev 02/15 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com W.C.C. No. __________________ 20. DID DECEASED EMPLOYEE RECEIVE WORKERS' COMPENSATION BENEFITS FOR THE ABOVE INJURY? UNDER A NON-PREDJUDICIAL AGREEMENT? Yes No UNDER A MEMORANDUM OF AGREEMENT? UNDER A DECREE OF THE WORKERS' COMPENSATION COURT? Yes No Yes No 21, WAS AN ESTATE OPENED? Yes No IF SO WHERE? NAME OF ADMINISTRATOR(S) OR EXECUTOR(S) 22. NAME OF PERSON PAYING BURIAL EXPENSES, AND AMOUNT PAID NAME, ADDRESS, RELATIONSHIP, AND AGE OF ALL DEPENDENTS OF DECEASED EMPLOYEE WHO WERE DEPENDENT AT THE TIME OF INJURY OR DEATH. NAME ADDRESS RELATIONSHIP TO DECEASED EMPLOYEE AGE OF MINORS CHECK THE BENEFITS YOU ARE SEEKING: WEEKLY BENEFITS PURSUANT TO R.I.G.L. §§ 28-33-12 AND 28-33-23 FUNERAL EXPENSES PURSUANT TO R.I.G.L. § 28-33-16 OTHER, PLEASE SPECIFY I hereby petition that my rights to benefits under the Workers' Compensation Act may be determined, and in support of this pleading I make the foregoing statements of fact: that both said employer and deceased employee were subject to the provisions of the Workers' Compensation Act; that said employee's injury was not occasioned by the employee's willful intention to bring about the injury or death of himself/herself or another; and that said injury did not result from the employee's intoxication on duty or unlawful use of controlled substances. I have attached a duly certified copy of the certificate of death along with any agreement or decree to pay workers' compensation benefits, if applicable. Attorney Name Signature of Petitioner Attorney Address and Phone Number Attorney Bar Registration Number Print Name of Petitioner Date Rev 05/15 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com