Rhode Island

The following steps should be taken when a work related injury or incident occurs.

Complete the Employee Incident Report

Please note: in the event of a catastrophic claim, contact Atlantic Charter Insurance Company immediately at 800.364.6662. This report should be completed jointly by the employee’s supervisor and the injured employee.

  • Section 1
    General Information

    Section 1 documents general information about the employee, when and where the incident occurred, who was involved, what treatment has occurred, and the employee’s current work status.

  • Section 2
    Employee’s Statement

    Section 2 should be completed by the injured employee. Only the employee should write a detailed statement explaining what occurred and what injury resulted. The employee should then sign the statement where it is indicated.

  • Section 3
    Employee’s Medical Authorization

    Section 3 is a medical release which the employee should be asked to sign. This release allows Atlantic Charter Insurance Company to access medical information pertaining to the injury which the employee is alleging.

Determine if the incident will result in more than three days of incapacity

Work-related injuries or illnesses must be reported if medical treatment is needed, if the injured worker is unable to earn full wages for more than three days, or if the injury is fatal. The three days do not have to be consecutive but should not include the date of injury. Such incidents should be reported to Atlantic Charter Insurance Company using both the Employee Incident Report as well as the Employer’s First Report of Alleged Occupational Injury, Disease or Fatality. Please include any other supporting documentation.

The printed, completed forms must be sent to Atlantic Charter Insurance Company (using the methods described in the adjacent box), given to the injured worker, and kept with your file.

The State of Rhode Island Department of Labor and Training (RIDLT) requires injuries to be reported electronically effective March 1, 2015. Upon receipt of the printed Employee Incident Report and Employer’s First Report of Alleged Occupational Injury, Disease or Fatality from the employer, Atlantic Charter Insurance Company will then file the First Report of Injury (FROI) electronically with the RIDLT on their behalf.

Fatal injuries must be reported to the RIDLT within 48 hours. Other injuries must be reported to the RIDLT within 10 days. Please note a penalty of $250 can be imposed by the RIDLT on employers for late filing or failure to file.

The Supervisor’s Investigative Report must also be submitted to Atlantic Charter Insurance Company.

Please email the completed Employee Incident Report and Employer’s First Report of Alleged Occupational Injury, Disease or Fatality to claims@atlanticcharter.com, or fax to (617) 488-6502. This is an automated email address for claim reporting only. Please do not send any other information to this email address as it will not be reviewed.

If necessary, these forms can also be mailed to:

Atlantic Charter Insurance Company
25 New Chardon Street
Boston, MA 02114
Attn: Claims Department