Page 1 of 2 State of Rhode Island and Providence Plantations Providence, S c . W orkers222 Compensation Court Name of Employee W.C.C. # - vs.- Insurance Carrier Name of Employer Insurance Carrier Address Request for Permission for Major Surgery The undersigned alleges as follows: The employer has has not been found liable under the terms of the Workers222 Compensation Act for an injury sustained by the employee on . (If applicable, attach a copy of any agreement or decree establishing liability) Dr. has stated that major surgery described as follows is necessary to cure, relieve or rehabilitate the employee from the effects of the injury. The proposed surgery is The employee has consented to the procedure and will undergo the surgery within days. Permission for surgery has been requested from the employer or its insurance carrier and has not been received. (Attach copy of such request). Wherefore the employee requests an ex-parte order granting permission for such surgery. Attorney for Employee Employee Address of A ttorney Address Attorney phone number and bar registration number Address W.C.C. Pending Cases American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 W.C.C. No. EX-PARTE ORDER Permission for surgery is granted to: Name of Surgeon Surgeon Address Surgeon Address Such surgery shall be performed within days from the date of this order. No liability of any kind is imposed upon the employer or its insurance carrier by this order. Dated this day of , 20. ENTER: PER ORDER: Judge Administrator American LegalNet, Inc. www.FormsWorkFlow.com