"Accident Witness Affidavit" - Rhode Island

Accident Witness Affidavit is a legal document that was released by the Rhode Island Department of Administration - a government authority operating within Rhode Island.

Form Details:

  • Released on May 1, 2015;
  • The latest edition currently provided by the Rhode Island Department of Administration;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Administration.

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Download "Accident Witness Affidavit" - Rhode Island

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STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
DEPARTMENT OF ADMINISTRATION
STATE EMPLOYEES WORKERS’ COMPENSATION
One Capitol Hill
Providence, RI 02908-5866
ACCIDENT WITNESS AFFIDAVIT
Date:
This is to certify that I was a witness to the accident/incident of:
Name:
Date of Injury:
Time of Injury:
Location of Injury:
Description of accident/incident:______________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________
Witness (Please print your name)
________________________________________
Signature of Witness
________________________________________
Telephone Number
OFFICE#: (401) 574-8500
FAX#: (401) 574-8524
TDD#: (401) 222-2187
Rev.5/2015
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
DEPARTMENT OF ADMINISTRATION
STATE EMPLOYEES WORKERS’ COMPENSATION
One Capitol Hill
Providence, RI 02908-5866
ACCIDENT WITNESS AFFIDAVIT
Date:
This is to certify that I was a witness to the accident/incident of:
Name:
Date of Injury:
Time of Injury:
Location of Injury:
Description of accident/incident:______________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________
Witness (Please print your name)
________________________________________
Signature of Witness
________________________________________
Telephone Number
OFFICE#: (401) 574-8500
FAX#: (401) 574-8524
TDD#: (401) 222-2187
Rev.5/2015