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Compensation DWC No. PO Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (401) 462-8006 FAX (401) 462-8105 Insurer File No. 1. EMPLOYER LOCATION: 2. EMPLOYER NAMED ON WC INSURANCE POLICY: FEIN FEIN Name Name Address Address City, State, Zip City, State, Zip Phone Ext. Type of Business RI Unemployment Ins. No. Phone NAICS SAME AS BLOCK 1 Ext. WC Policy Number 3. INSURANCE COMPANY NAMED ON WC POLICY: 4. CLAIM ADMINISTRATOR: FEIN FEIN Name Name Address Addres.

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