Department Of Labor And Training Notice Of Claim Of Common Law Rights
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1State 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
Soc. Sec. No.
Address
Date of Birth
an employee of the following business,
Name
DBA
Address
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.
For a dated receipt copy, include a copy with the original sent to the Department with a self
addressed, stamped envelope. The original and copy will be date stamped. The original will be
retained for our files. The stamped copy will be returned in the envelope provided.
DWC-11 (1/2002)
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