Rescission Of Agreement For Electronic Payment Of Workers Comp Benefits {DWC-EB2}

Claim Administrator Claim Number Employee Information Employer, Insurer & Claim Administrator RI Department of Labor and Training, Division of Workers' CompensationPO Box 20190, Cranston, RI 02920-0942www.dlt.ri.gov/wc Phone 401-462-8100 Fax 401-462-8105 SSN or IDDate of Birth Last Name First Name Initial Date of Injury Employer NameInsurer NameDate of Claim Administrator Name Employee Signature Date Signature American LegalNet, Inc. www.FormsWorkFlow.com