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Rhode Island Form Center -

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Form

Description

dwc01.pdf Employer's First Report of Alleged Occupational Injury or Disease Electronic submission of FROI and SROI are mandatory by 3/1/2015. For internal use only.
dwc52.pdf Subsequent Report - Electronic Reporting ONLY After 3/1/2015. For internal use only.
dwc02.pdf Memorandum of Agreement
dwc03f.pdf Wage Statement: Full Time
dwc03p.pdf Wage Statement: Part Time
dwc03s.pdf Wage Statement: Seasonal
dwc04.pdf Employee's Certificate of Dependency Status
dwc05.pdf Suspension Agreement and Receipt
mab01hcp.pdf Affidavit of Healthcare Professional
mab01.pdf Affidavit of Physician
attylumpwksht.pdf Attorney Worksheet for Lump Sum or Structured-Type Settlements
certofsvc.pdf Certificate of Service
civilcase.pdf Civil Case Cover Sheet - Electronic Filing
claimtrial.pdf Claim For Trial
claimappeal.pdf Claim of Appeal to the Appellate Division
wcc-9.pdf Employee's Petition for Compensation Benefits
employeepet.pdf Employee's Petition to Review and/or Amend Agreement or Decree Concerning Compensation
employerpet.pdf Employer's Petition to Review and/or Amend Agreement or Decree Concerning Compensation
eb1.pdf Agreement For Electronic Payment of Workers' Compensation Benefits
eb2.pdf Rescission of Agreement for Electronic Payment of Workers' Compensation Benefits
dwc09.pdf Insurance Coverage Certification For Temporary Employment and Employee Leasing Companies
dwc11.pdf Notice of Claim of Common Law Rights
dwc11-sp.pdf Notice of Claim of Common Law Rights (Spanish)
dwc11r.pdf Rescind Notice of Claim of Common Law Rights
dwc11r-sp.pdf Rescind Notice of Claim of Common Law Rights (Spanish)
dwc11c.pdf Election by Exempt Corporate Officer to Become Subject to Workers' Compensation Not Available on line. Call 401 462-8100 option 7 for information
dwc11-ic.pdf Notice of Designation as an Independent Contractor
dwc11-ic-sp.pdf Notice of Designation as an Independent Contractor (Spanish)
dwc11-icr.pdf Notice of Withdrawal of Designation as Independent Contractor
dwc11-icr-sp.pdf Notice of Withdrawal of Designation as Independent Contractor (Spanish)
dwc20.pdf Non-Prejudicial Agreement
dwc21.pdf Termination of Benefits
dwc24.pdf Mutual Agreement
dwc25.pdf Report of Earnings
dwc27-28.pdf Physician's Notice of Release to Work
dwc29.pdf Notification of Claim of Compensable Injury
dwc30.pdf Wage Transcript
dwc31.pdf Employee's Objection to Wage Transcript
dwc32.pdf Notice to Employees Regarding Benefit Check
dwc32-sp.pdf Notice to Employees Regarding Benefit Check (Spanish)
dwc36.pdf Coordination Of Retirement Benefits
dwc40.pdf Request For Additional Palliative Care
SelfinsuredApp.pdf Application For Approval of Workers Compensation Self-Insurance Program
RenewalApp0312.pdf Self-Insured Renewal Application
RISI-5aJan12.pdf Surety Bond Extension Agreement
RISI-5.pdf Bond of Employer Authorized to pay Workers' Compensation benefits Directly to Employees or their Dependents
RISI-5Bjan2012.pdf Bond of Employer Authorized to pay Workers' Compensation benefits Directly to Employees or their Dependents
RISI-5cbackdate.pdf Bond of Employer Authorized to pay Workers' Compensation benefits Directly to Employees or their Dependents
risi6.pdf Standby Letter of Credit
Escrow.pdf Escrow Agreement
TrustAgreement.pdf Trust Agreement
RISI-7b.pdf Certificate of Deposit Agreement
RISI-9Certificate.pdf Certificate
RISI-9aCert.pdf Certificate
risi10.pdf Indemnity Agreement
si14form12.pdf Claims Loss Summary
risi14b.pdf Required Data Fields Claims Listing
RISI-15.pdf Calculated Security Requirement
licinsrtf.pdf Licensed Insurers Assessment Return Form
RIisi17.pdf Self-Insurance Agreement
risi17b.pdf Self Insurance Agreement Continuation, Extension and/or Amendment
referralform.pdf Donley Rehabilitation Center Referral Form
ReferralForm_AquaticTherapy.pdf Donley Rehabilitation Center Referral Form Aquatic
Fraud_referral.pdf Fraud & Compliance Unit Claim Referral/Initial Information Report
pubrec.pdf Request for Public Information
dwc08.pdf POSTER - WC Act Summary
dwc08-sp.pdf POSTER - WC Act Summary Spanish)
Compliance.pdf BROCHURE - What Employers Should Know About Workers' Compensation
Brochure.pdf BROCHURE - Information You Need To Know About Workers' Compensation Insurance
Brochure_sp.pdf BROCHURE - Information You Need To Know About Workers' Compensation Insurance (Spanish)
Fraud.pdf BROCHURE - Worker's Compensation Fraud